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Research ArticleOriginal Research

Updated Priorities Among Effective Clinical Preventive Services

Michael V. Maciosek, Amy B. LaFrance, Steven P. Dehmer, Dana A. McGree, Thomas J. Flottemesch, Zack Xu and Leif I. Solberg
The Annals of Family Medicine January 2017, 15 (1) 14-22; DOI: https://doi.org/10.1370/afm.2017
Michael V. Maciosek
HealthPartners Institute, Minneapolis, Minnesota
PhD
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  • For correspondence: michael.v.maciosek@healthpartners.com
Amy B. LaFrance
HealthPartners Institute, Minneapolis, Minnesota
MPH
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Steven P. Dehmer
HealthPartners Institute, Minneapolis, Minnesota
PhD
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Dana A. McGree
HealthPartners Institute, Minneapolis, Minnesota
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Thomas J. Flottemesch
HealthPartners Institute, Minneapolis, Minnesota
PhD
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Zack Xu
HealthPartners Institute, Minneapolis, Minnesota
MS
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Leif I. Solberg
HealthPartners Institute, Minneapolis, Minnesota
MD
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Tables

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    Table 1

    Scoring Ranges

    ScoreCPBa Range: QALYb Saved, UndiscountedCEc Range: $/QALY Saved, Discounted
    5>700,000Cost-saving
    4190,000–700,0000–3,500
    370,000–190,00033,500–50,000
    218,000–70,00050,000–75,000
    1<18,000>75,000
    • CE = cost-effectiveness; CPB = clinically preventable burden; QALY = quality-adjusted life year.

    • ↵a A measure of the health impact of a preventive service.

    • ↵b Years saved if the clinical preventive services were delivered at recommended intervals to a US birth cohort of 4 million patients during the years of life for which a service was recommend.

    • ↵c Measure of efficiency of the service in producing health improvement.

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    Table 2

    Priorities for Improving Utilization of Clinical Preventive Services

    Services (Short Name)DescriptionCPBCETotal
    Childhood immunization seriesACIP childhood immunization seriesa5510
    Tobacco use, brief prevention counseling, youthProvide interventions to prevent initiation, including education or brief counseling5510
    Tobacco use screening and brief counseling, adultsScreen adults for tobacco use and provide brief cessation counseling and pharmacotherapy5510
    Alcohol misuse screening and brief interventionScreen adults’ misuse and provide brief counseling to reduce alcohol use358b
    Aspirin chemoprevention for those at higher risk of CVDLow-dose aspirin use for primary prevention of CVD in adults ages 50–59 y with ≤10%, 10-y CVD risk and other factors358
    Cervical cancer screeningScreen for cervical cancer in women aged 21 to 65 y with cytology (Papanicolaou smear) every 3 y448
    Colorectal cancer screeningScreen adults aged 50–75 y routinely448b
    Chlamydia and gonorrhea screeningScreen for chlamydia and gonorrhea in sexually active women aged ≤24 y, and in older women at increased risk for infection347b
    Cholesterol screeningScreen routinely for lipid disorders men aged >35 y, and screen younger men and women of all ages who are at increased risk of CHD. Treat with lipid-lowering medications437
    Hypertension screeningMeasure blood pressure routinely in all adults and treat with antihypertensive medication to prevent the incidence of CVD437
    AAA screeningScreen men aged 65–75 y who have ever smoked 1 time for abdominal aortic aneurysm, using ultrasonography246b
    Healthy diet and physical activity counseling for those at higher risk of CVDOffer or refer adults who are overweight or obese with additional CVD risk factors to intensive behavioral counseling to promote healthful diet and physical activity516
    HIV screeningScreen for HIV infection in adolescents and adults aged 15 to 65 y. Frequency varies by risk level246b
    HPV immunizationAdminister a 3-dose series of HPV vaccine to all girls aged 11–12 y336
    Influenza immunization, adultsImmunize all adults against influenza annually426b
    Obesity screening, adultsScreen all adults routinely for obesity. Refer patients with a BMI of ≥30 kg/m2 to intensive behavioral interventions516b
    Syphilis screeningScreen all persons at increased risk for syphilis infection156
    Vision screening, childrenScreen children routinely between ages 3 and 5 y to detect amblyopia246b
    Breast cancer screeningBiennial mammography for women aged 50–74 y; screening before age 50 y an individual decision325b
    Depression screening, adolescentsScreen adolescents aged 12–18 y for depression with systems to assure accurate diagnosis, treatment, and follow-up235b
    Depression screening, adultsScreen adults for depression with systems to assure accurate diagnosis, treatment, and follow-up325b
    Obesity screening, children and adolescentsScreen children aged ≥6 y for obesity. Offer or refer obese children to comprehensive, intensive behavioral intervention415
    Pneumococcal immunization, adultsImmunize adults aged >65 y against pneumococcal disease with PCV13 and PPSV23235b
    Herpes zoster immunizationSingle dose of vaccine for adults aged >60 y134
    Osteoporosis screeningScreen women aged >65 y and younger women whose fracture risk is equal to or greater than that of white women aged 65 y with no additional risk factors224
    Folic acid chemopreventionWomen planning or capable of pregnancy should take a daily supplement with 0.4–0.8 mg of folic acid123
    Meningococcal immunizationSingle dose of quadrivalent vaccine recommended for children aged 11 to 12 y, with a booster at age 16 y112
    Tdap/Td boosterOne time Tdap and Td booster every 10 y112
    • AAA = abdominal aortic aneurysm; ACIP = Advisory Committee on Immunization Practices; BMI = body mass index; CE = cost-effectiveness; CHD = coronary heart disease; CPB = clinically preventable burden; CVD = cardiovascular disease; HIV = human immunodeficiency virus; HPV = human papillomavirus; PCV13 = pneumococcal conjugate vaccine—13 pneumococcal serotypes; PPSV23 = pneumococcal polysaccharide vaccine—23 pneumococcal serotypes; Td = tetanus, diphtheria; Tdap = tetanus, diphtheria, and pertussis.

    • ↵a Estimate includes all recommended vaccines up to 10 years of age (diphtheria, tetanus, pertussis; measles, mumps, rubella; inactivated polio virus; Hemophilus influenzae type b; hepatitis A; hepatitis B; varicella; pneumococcal conjugate; influenza; and rotavirus) plus influenza vaccination to age 18 years.

    • ↵b Sensitivity analysis indicated that a change of score of 2 or more is possible.

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    Table 3

    QALYs Saved if Utilization Rates Increase Above Current Levels

    Services (Short Name)aSourceCurrently Receiving Services Nationallyb %Additional QALY Saved if Currently Receiving Services Increased to 90%c
    Services with utilization data available
     Tobacco use counseling to prevent initiation by youthdJamal2320530,000
     Tobacco use screening and brief cessation intervention, adultsNCQA24
    Jamal25
    King26
    50460,000
     Alcohol misuse screening, brief interventionMcKnight-Eily2710140,000
     Colorectal cancer screeningCDC2865110,000
     Influenza immunization, adultsCDC2945100,000
     HPV immunizationdReagan-Steiner305059,000
     Breast cancer screeningNCHS31
    CDC28
    7542,000
     Chlamydia and gonorrhea screeningdCDC324039,000
     HIV screeningChandra332032,000
     Aspirin chemoprevention for those at higher risk of CVDWilliams345030,000
     Cervical cancer screeningNCHS31
    CDC28
    8514,000
     Vision screening, childrenKemper35755,000
     Pneumococcal immunization, adultsCDC28704,000
    Services with utilization data assigned at 50%
     Obesity screening, adultseAssigned50540,000
     Healthy diet counseling for those at higher risk of CVDeAssigned50300,000
     Obesity screening, children and adolescentsd,eAssigned5078,000
     Depression screening, adultseAssigned
    Farr36
    Edwards37
    5045,000
     AAA screeningeAssigned
    Shreibati38
    5021,000
     Depression screening, adolescentsd,eAssigned5011,000
     Syphilis screeningeAssigned502,000
    • AAA = abdominal aortic aneurysm; CDC = Centers for Disease Control and Prevention; CMS = Centers for Medicare & Medicaid Services; CPS = Community Preventive Services; CVD = cardiovascular disease; FDA = Food and Drug Administration; HIV = human immunodeficiency virus; HPV = human papillomavirus; QALY = quality-adjusted life years; USPSTF = US Preventive Services Task Force.

    • ↵a See Table 2 for a description of each service. Childhood immunizations, hypertension screening, and cholesterol omitted from table because of current high utilization rates.

    • ↵b Current utilization rates rounded and reflect approximate average of male and female patients, across all relevant age-groups and other important groups for a service, such as groups at high and low risk for disease.

    • ↵c Indicates additional lifetime QALYs saved if 90% of a cohort of 4 million were offered service as recommended.

    • ↵d Youth services estimated based on a target of 90% of youth receiving service annually, although slightly less than 90% of adolescents aged 12–17 years saw a health care professional in 2012.

    • ↵e Based on limited utilization data. Utilization data were considered limited if existing information was difficult to use to quantify utilization rates and place an upper boundary more precise than 50%. Either utilization data are completely lacking or are available only for a population for which generalizability to US population is highly questionable, or the utilization measures available are poorly aligned with the preventive service as recommended by the USPSTF.

Additional Files

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    Supplemental Appendix

    Files in this Data Supplement:

    • Supplemental data: Appendix - PDF file
  • The Article in Brief

    Updated Priorities Among Effective Clinical Preventive Services

    Michael V. Maciosek , and colleagues

    Background The National Commission on Prevention Priorities has updated its 2006 rankings of 28 clinical preventive services. The Commission used sophisticated microsimulation modeling to estimate the relative health impact and cost-effectiveness of each service. The findings are intended to assist clinicians and other decision-makers in their efforts to plan quality improvement initiatives, develop performance measurements, build primary care medical homes, and incorporate preventive services into the contracts of accountable care organizations.

    What This Study Found The three highest ranking preventive services are immunizing children, counseling to prevent tobacco initiation among youth, and tobacco-use screening and brief intervention to encourage cessation among adults. Other high-ranking services include alcohol misuse screening with brief intervention; discussing aspirin use with high-risk adults; screenings for colorectal cancer, cervical cancer, chlamydia and gonorrhea, cholesterol, hypertension, and obesity; healthy diet counseling for those at a higher risk of cardiovascular disease; abdominal aortic aneurysm screening in high risk men; HIV screening; human papillomavirus immunization; influenza immunization; syphilis screening; and vision screening for children.

    Implications

    • There are substantial opportunities for primary care to improve population health through increased implementation of these evidence-based services.
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The Annals of Family Medicine: 15 (1)
The Annals of Family Medicine: 15 (1)
Vol. 15, Issue 1
January/February 2017
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Updated Priorities Among Effective Clinical Preventive Services
Michael V. Maciosek, Amy B. LaFrance, Steven P. Dehmer, Dana A. McGree, Thomas J. Flottemesch, Zack Xu, Leif I. Solberg
The Annals of Family Medicine Jan 2017, 15 (1) 14-22; DOI: 10.1370/afm.2017

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Updated Priorities Among Effective Clinical Preventive Services
Michael V. Maciosek, Amy B. LaFrance, Steven P. Dehmer, Dana A. McGree, Thomas J. Flottemesch, Zack Xu, Leif I. Solberg
The Annals of Family Medicine Jan 2017, 15 (1) 14-22; DOI: 10.1370/afm.2017
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Subjects

  • Domains of illness & health:
    • Prevention
    • Health promotion
  • Person groups:
    • Older adults
    • Women's health
    • Children's health
    • Vulnerable populations
    • Community / population health
  • Methods:
    • Quantitative methods
  • Other research types:
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    • Health services
    • PBRN research
    • POEMs
  • Core values of primary care:
    • Personalized care
  • Other topics:
    • Quality improvement
    • Clinical practice guidelines
    • Disparities in health and health care

Keywords

  • disease, prevention & control
  • health services
  • economics
  • prioritization
  • health impact
  • cost-effectiveness
  • cost-savings
  • immunization
  • mass screening
  • behavioral counseling

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