Table of Contents
The Issue 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.
Steven P. Dehmer , and colleagues
Background Cardiovascular disease (CVD) is the leading cause of death and one of the greatest causes of illness in the United States today. Total direct and indirect costs are estimated to exceed $300 billion annually and total direct medical costs are projected to triple by 2030. This study updates estimates of the health and economic impact of three services recommended for preventing CVD: cholesterol screening, lipid screening, and aspirin counseling.
What This Study Found All three services continue to rank highly among recommended preventive services for U.S. adults in primary care. Health impact is highest for hypertension screening and treatment, closely followed by cholesterol screening and treatment. Aspirin counseling has lower health impact but is cost saving. Outcomes for subgroups of the population sometimes diverge in meaningful ways from the population average. For example, findings favor hypertension over cholesterol screening for women, and opportunities to reduce disease burden across all services are greatest for the non-Hispanic black population.
Implications
- Clinical services to prevent CVD can avert substantial disease burden and save costs. Such services should remain among the top prevention priorities for adults in primary care.
- Individual priorities should be tailored by taking a patient's demographic characteristics and clinical objectives into account.
Health Benefits and Cost-Effectiveness of Brief Clinician Tobacco Counseling for Youth and Adults
Michael V. Maciosek , and colleagues
Background In the US, 42 million adults continue to smoke, and in 2015, 1.6 million middle- and high-school students self-reported smoking tobacco in the last 30 days. Smoking is still the leading cause of preventable death in the United States, with direct medical costs of about $175 billion per year. This study assesses the long-term value of providing brief, annual tobacco counseling to both youth and adults.
What This Study Found Brief tobacco counseling provides substantial health benefits while producing cost savings and is therefore a high-priority use of limited clinician time. Annual counseling for youth would reduce the average prevalence of smoking cigarettes during adult years by two percentage points. Annual counseling for adults would reduce prevalence by 3.8 percentage points. Youth counseling would prevent 42,686 smoking-attributable fatalities. Adult counseling would prevent 69,901 smoking-attributable fatalities. Youth and adult counseling would yield net savings of $225 and $580 per person, respectively. If annual tobacco counseling was provided during both youth and adult years, then adult smoking prevalence would be 5.5 percentage points lower compared with no counseling, and there would be 105,917 fewer smoking-attributable fatalities over their lifetimes. At current rates, only one-third of the potential health and economic benefits of counseling are being realized.
Implications
- Tobacco counseling can produce more meaningful improvements in population health with good stewardship of health care system resources than almost any other preventive service.
Barry G. Saver , and colleagues
Background Patients face many medical decisions. Decisions are, however, shaped by a variety of human and social factors, and evidence for decision-making is often complicated and incomplete. This study tests novel video decision aids designed to help patients trust and accept controversial U.S. Preventive Services Task Force recommendations, a) against screening for prostate cancers with the prostate specific antigen test and b) that women in their 40s should make an informed choice about mammography.
What This Study Found While a more traditional, print decision aid had no effect on participants' screening intentions, recorded video vignettes of physician-patient discussions about the recommendations significantly changed the screening intentions of a substantial proportion of participants. At entry, 86 percent of the 35 women in the study reported wanting screening, 6 percent were unsure, and 9 percent did not want screening. At the study end, 49 percent of the women wanted screening, 20 percent were unsure, and 29 percent did not want screening. At entry, 69 percent of the 27 men who participated in the study reported wanting prostate screening, and 31 percent were unsure. After exposure to both interventions, 33 percent wanted screening, 11 percent were unsure, and 56 percent did not want screening.
Implications
- The authors note while this novel, persuasive video approach needs further testing, the findings are far more promising than those previously reported for many other decision aids. This approach may serve as a model for persuasive interventions for helping patients consider and accept evidence-based, counterintuitive recommendations and reduce use of low-value procedures.
Diane R. Rittenhouse , and colleagues
Background Health information technology (HIT) is one of the foundations of high-performing primary care, but adoption of HIT by primary care practices is far from universal. This study analyzes data from telephone surveys of small primary care practices to better understand the correlates of greater health information technology implementation.
What This Study Found Sixteen out of 18 measures of health information functionality increased during the study period, with largest gains among hospital-owned practices, practices with 3 to 8 (versus 1 to 2) physicians, practices with more Medicare patients, and those participating in pay-for-performance or public reporting of quality data. Physician use of electronic health records to collect quality data increased from 17 percent to 42 percent and e-prescribing increased from 25 percent to 70 percent over time. Hospital-owned practices used on average 1.5 more HIT processes than physician-owned practices, and practices with 3 to 8 physicians used 2.5 more HIT processes than smaller practices. External incentives (participation in pay-for-performance programs, participation in public reporting of clinical quality data, and greater proportion of revenue from Medicare) were also positively associated with greater adoption and use of HIT, although the effect sizes were smaller. The authors note that despite substantial increases in adoption and use of HIT, there remains ample room for improvement. Fewer than 50 percent of practices reported using most EHR functionalities. Only one in five practices used e-mail with patients or allowed patients to see their medical records online, and maintenance of electronic registries for the management of chronic disease was also low.
Implications
- The authors conclude that targeting assistance to smaller, physician-owned practices and offering payment incentives and technical support would help encourage uptake and use of HIT in primary care.
Regional Variation in Primary Care Involvement at the End of Life
Andrew W. Bazemore , and colleagues
Background Primary care improves patient care through coordination of care and services, continuity of relationships, and comprehensiveness of practice, but more information is needed about primary care physician (PCP) participation in end of life care. This study examines regional variation in PCP involvement in the end of life and the association of such involvement with end of life outcomes.
What This Study Found Regions of the country with greater primary care physician involvement in the last 6 months of life have lower-intensity, lower-cost end-of-life care. Chronically ill adults in regions with greater primary care physician involvement have less care in the intensive care unit in their last 6 months of life and are less likely to have more than 10 physicians in their care. These regions also have less costly end-of-life care, despite lower rates of hospice use.
Implications
- These findings can help us better understand and optimize the role of primary care physicians in care at the end of life in order to both improve the care of the dying and reduce unnecessary and costly intensive care.
Maternal Preferences for Vitamin D Supplementation in Breastfed Infants
Tom D. Thacher , and colleagues
Background Although daily vitamin D supplementation is recommended for breastfed infants, adherence to this recommendation is poor. This study explores mothers' preferences for vitamin D supplementation.
What This Study Found Less than one-half of infants in the study received the recommended daily vitamin D supplementation. Given a choice, most mothers prefer to supplement themselves to enrich their breast milk with vitamin D rather than supplement their infants. Among 140 mothers with exclusively breastfed infants and 44 who used both breast milk and formula milk, 55 percent supplemented their infants with vitamin D, and 42 percent supplemented with the 400 IU recommended. Eighty-eight percent of mothers preferred supplementing themselves rather than their infants, and 57 percent preferred daily to monthly supplementation. Mothers cited safety as most important in choosing a method of supplementation.
Implications
- Taking mothers' preferences into consideration could improve adequate intake of vitamin D in breastfed infants. Because most mothers take a prenatal vitamin after delivery, higher doses of vitamin D (4000-6400 IU daily) could be incorporated into their supplementation routine.
Measuring Outcomes: Lessons From the World of Public Education
John W. Saultz , and colleagues
Background Quality and efficiency in American health care are increasingly measured using clinical and financial data. Similar performance management policies have been implemented in public education. In this article, 2 researchers, one with a background in education policy and the other in primary care, outline how outcomes measurement and public reporting of quality data in public education can serve as both a positive example and a cautionary tale for similar changes underway in health care.
What This Study Found Performance measurement techniques can be useful if properly applied, and, according to the authors, opposition will not cause such efforts to go away. They recommend that health policy leaders not discount the expertise of physicians as educational policy leaders have with teachers, focusing on a narrow list of outcomes; rather, policy leaders should recognize the limitations of business models in service sectors, reconnect with local communities, and more effectively listen to their voices. The unintended consequences of poorly implemented performance management in both education and health care include the narrowing of purpose, deprofessionalization, and a loss of community control.
Implications
Elizabeth R. Volkmann
Background A physician shares her experience as a survivor of sexual violence and as a provider for patients whose wounds from these traumas have flourished in atmospheres of shame and stigma.
What This Study Found The author's deeply personal insights demonstrate how physicians and other clinicians can play a central role in restoring the health of individuals who silently suffer sexual assault.
Neuroscience, Joy, and the Well-Infant Visit That Got Me Thinking
Tamas Ungar
Background A family physician uses recent neuroscience findings to examine how mutual gaze between a mother and her newborn critically impacts early infant brain development.
What This Study Found Reflecting on a well-visit in which a new mother expressed concern that her 4-month old was "staring into blank space," the author explains why he counsels new parents to hold their infants close, encourage efforts to babble and coo, be mindful of opportunities for mutual play, and encourage the basic innate joy in their interactions with their babies. Mutual gaze is a deeply ingrained mechanism for the development of important parts of the brain and allows for a healthy integration of self through the transmission and regulation of emotion. Because new parents are closest to their babies, it is mainly their gaze interactions during brief joyful moments that serve to develop the infant's own sense of self.
Implications
- The author concludes that family physicians can effect the lives of their littlest patients in meaningful ways by sharing this powerful insight during well-infant and post-partum visits.