Prevention Barbara Starfield, MD, MPH Seminar: 16 th Nordic Conference on National and Global Cooperation in Health Copenhagen, Denmark May 2009

Prevention

Barbara Starfield, MD, MPH

Seminar: 16th Nordic Conference on National and Global Cooperation in Health

Copenhagen, DenmarkMay 2009

Why Is the Concept of Prevention Much More Difficult

Now Than in the Past?

• What we are trying to prevent is much less well-defined.

• Chain of influences is much more complex.• Likelihood of success is less predictable.• Likelihood of adverse events is greater.

Starfield 02/09PREV 4149

A review of 1500 interventions for prevention and treatment found that about one in five lowered costs. The rest (80%) added more costs than they saved.

Starfield 04/09PREV 4175Source: Russell, Health Aff 2009;28:42-5.

Cost Effectiveness of “Clinical Prevention”

Starfield 02/09PREV 4127 n

Hypertension For those with very high blood pressure; depends on age and particular drug cost

Statins For established heart disease in men

Aspirin If ten-year risk of death is 5% or greater, in men

Diabetes (lifestyle change) Borderline, at best

Screening (cervical cancer, colorectal cancer, breast cancer)

Are cost-increasing

Osteoporosis Over age 65 in women; depends on cost of bisphosphonates

DISEASE management

Asthma Self management costs more than traditional care.

Pneumococcal pneumonia vaccination

Adults with chronic diseases

Source: Russell, Health Aff 2009;28:42-5.

Comment: A major problem with prevention is that interventions are not prioritized. Perhaps contributions to increasing equity in health should be a major consideration in setting priorities?

Distribution of Cost-effectiveness Ratios for Preventive Measures and Treatments for Existing

Conditions

Starfield 02/09PREV 4128 nSource: Russell, Health Aff 2009;28:42-5.

QALY = quality-adjusted life-year

Prescribed exercise, for women ages 40-74 over 12 months in New Zealand, increased rates of physical activity and increased SF-36 physical functioning and mental health but reduced physical fitness, did not change intermediate outcomes (BP, serum lipids, HBA1c, glucose, insulin), and significantly increased rates of falls and injuries.

Source: Lawton et al, BMJ 2009;337:a2509. Starfield 02/09PREV 4129

On the basis of preventable burden and cost effectiveness, the National Commission on Preventive Priorities listed:

HIGHEST PRIORITY: daily aspirin (men 40+, women 50+); child immunizations; tobacco use screening

HIGH: screening for colorectal cancer (50+), adult hypertension, visual acuity (65+); flu vaccine (50+)

LOWER: screening for cervical cancer (sexually active), cholesterol (men 35+, women 45+), breast cancer (50+), Chlamydia (sexually active), vision (under age 5), obesity; calcium use (female teens and adults); folic acid (childbearing ages)

NO EVIDENCE OF UTILITY: general population counseling in clinical practice

Starfield 02/09PREV 4130Source: Maciosek et al, Am J Prev Med 2006;31:52-61.

Cost-effectiveness of Public Health Prevention: Cost Saving


One-time colorectal cancer screening; HIV type B and hepatitis A/B immunizations; condom distribution; seat-belt law; hip protectors for women; drowning prevention; street lights; livestock control; HIV testing of donated blood; tuberculosis test and treatment

Source: Neumann et al, Am J Public Health 2008;98:2173-80.

NOTE: Only one reference cited for each; validity not confirmed and interpretation not generalizable to all populations.

Cost-effectiveness of Public Health Prevention: under $50,000 per QALY


Diabetic retinopathy screening in type 2 diabetes; genetic screening for rheumatic fever; proteinuria screening; newborn screening for acyl-CoA dehydrogenase, tandem mass spectrometry; screening for cystic fibrosis carriers; universal HPV vaccination; RSV vaccination; vitamin supplementation to lower plasma homocysteine; OTC smoking cessation drugs; intensive school anti-tobacco education; accessible external defibrillators; HIV risk reduction and counseling; auto air bags; suicide prevention programs; alanine aminotransferase testing of fresh-frozen plasma; donor heart and liver transplantation; vaccination against invasive pneumcoccal disease



Cost-effectiveness of Public Health Prevention: Borderline Cost Effective

($50-100,000 per QALY)


Continued PAP/HPV testing into old age; screening for type 2 diabetes over age 24; increasing rates of immunization for measles; pneumococcal vaccination; regulations for use of phones while driving; HIV post-exposure prophylaxis; HIV cognitive-behavioral risk reduction; solvent detergent treatment of fresh frozen plasma



Cost-effectiveness of Public Health Prevention: Not Cost Effective

(Greater Than $100,000 per QALY)


Emission-controlled urban transit buses; cancer surveillance in Barretts esophagitis



INTERVENTIONS THAT WORK• Antiobiotics for moderate-severe cellulitis• Antiobiotics for bacterial pneumonia• Beta-agonists for asthma symptoms• Steroid cream for eczema• Opioids for acute or chronic pain• Acetoaminophen for osteoarthritis• Diuretics for heart failure• Antiviralsfor HIV• Beta blockers for migraine

Source: McCormick J. Vancouver IHI presentation, March 2009

• Source: McCormick J. Vancouver IHI presentation, March 2009

Effectiveness of CCM Interventions: COGNITIVE DISSONANCE?

Starfield 02/09D 4125

“Variations in nomenclature used by authors and imprecise descriptions of interventions made it difficult to meaningfully identify CCM-based interventions.”

Of 944 papers, only 82 were in primary care and included at least 4 of the CCM components.

Most were from the US and all were disease-oriented

“Accumulated evidence appears to support (italics added) CCM as an integrated framework to guide practice redesign.”

Accompanying editorial: “The shows that the CCM extends quality-adjusted life years at a cost-effective price”.

Sources: Coleman et al, Health Aff 2009;28:75-85. Dentzer, Health Aff 2009;28:63.

The Alternative Chronic Care Model (A-CCM): a Six-step Innovation

• Early intervention – to detect deterioration • Integration of care – exchange of data and

communication across multiple co-morbidities, multiple providers, and complex disease states

• Coaching – to encourage patient input and participation• Connectedness – patients and providers• Workforce changes – to lower-cost and more plentiful

health care workers• Increased productivity – decreased travel time and

automated transfer of information and documentation

Starfield 02/09D 4145Source: based on Coye et al, Health Aff 2009;28:126-35.

Monitoring Does Not Require Patient Visits in Well-organized Health Systems

For example, the US Veterans Health Administration achieved a 60% reduction in hospital admissions and a 66% reduction in ED visits among 281 Remote Patient Management (RPM) monitored veterans with congestive heart failure, in comparison with 1120 veterans not using the technology.

THE CHALLENGE IS TO ASSURE THAT WHOLE-PATIENT CARE IS ENHANCED, NOT COMPROMISED, BY THIS INNOVATIVE TECHNOLOGY.

Starfield 02/09D 4146Source: based on Coye et al, Health Aff 2009;28:126-35.

The evaluation “Review of the Implementation of CARE PLUS” indicates that most of the programs used the Chronic Care Model, although no description is specified of the components of this model in practice. The process and outcome evaluation showed INCREASES in all utilization, including physician visits, emergency department, and ambulatory care sensitive hospitalizations, and no quality improvements (prescribing) except for increases in the prescribing of metformin in diabetes.

Starfield 02/09D 4147

If anything, this evaluation indicates that a focus on specific chronic illnesses is unlikely to lead to improved health, particularly in populations that have higher morbidity burdens overall.

Source: CBG Health Research Limited. Review of the Implementation of CARE PLUS. Ministry of Health, New Zealand, 2006.

Is Prevention Disease or Health Oriented?

Starfield 02/09PREV 4126 n

Disease oriented? Target

Y Social change: community change

N Social change: public health efforts (promotion and protection)

Y Individual change: screening and treatment

N Social change: population-based primary care

Source: prompted by reaction to Goetzel RZ, Health Aff 2009;28:37-41.

Documents

Prevention Barbara Starfield, MD, MPH Seminar: 16 th Nordic Conference on National and Global Cooperation in Health Copenhagen, Denmark May 2009