Research articleDeaths Preventable in the U.S. by Improvements in Use of Clinical Preventive Services
Introduction
How can the healthcare system save the most lives? This simple question, which is important to inform the implementation of healthcare reform, has not, to our knowledge, been systematically addressed in the medical literature.
In recent years, systematic reviews of scientific evidence have identified clinical interventions that prevent illness and reduce mortality. However, time-pressured clinicians are forced to make choices about which of these clinical preventive services to offer during brief clinical encounters.1, 2 In the U.S., only slightly more than half of recommended healthcare interventions are provided during the course of normal care.3 Perhaps the most important improvement in the quality of medical care could be increasing the proportion of people who receive clinical interventions that are demonstrated to reduce mortality.
To inform the current discussion on healthcare reform, it would also be useful to estimate the benefit of routinely providing the most effective preventive services. There have been few attempts to assess the relative or cumulative value of clinical preventive services in entire populations, and those that have been published have not estimated the marginal improvement in deaths prevented by increasing the use of these interventions from current levels of use.4, 5
The potential population benefit of a clinical preventive intervention cannot be determined solely by the benefit it offers an individual. The population benefit also depends on the prevalence of risk factors in the population, the degree to which the population is already receiving the intervention, and the potential increase in the proportion of the population that could receive the intervention. For this study, mathematical models were developed to estimate the number of deaths that could be prevented by increasing the utilization for nine clinical preventive services in the U.S. population.
Section snippets
Selected Interventions
Initial consideration was given to clinical preventive services that received the highest level of recommendation (Grade A) from the U.S. Preventive Services Task Force (USPSTF) and are known to prevent the top two categories of causes of death in the U.S.: cardiovascular disease and cancer. Consideration was also given to one clinical preventive service with a USPSTF Grade-B rating (mammography) and two widely used immunizations recommended by the Advisory Committee on Immunization Practices
Effect of Varying Target Utilization Levels
The potential benefit of increasing utilization of services on deaths prevented in those aged <80 years is shown in Figure 1 (all-cause model) and Figure 2 (cause-specific model). Both models predicted that among all services considered, treatment of hypertension had the potential to prevent the most deaths and that treatment of hyperlipidemia and aspirin prophylaxis also had high potential. For example, the all-cause model predicted that every 10% increase in hypertension treatment would lead
Discussion
The models predicted that the clinical preventive services that would prevent the greatest number of deaths are those that reduce cardiovascular disease, particularly treatment of hypertension, treatment of hyperlipidemia, and aspirin prophylaxis. These services have the potential to prevent large numbers of deaths because the risk factors they address are common, they are relatively effective in reducing both cause-specific and all-cause mortality in those with these risk factors, and their
Acknowledgments
The authors thank Dr. Kevin Konty for statistical assistance.
No financial disclosures were reported by the authors of this paper.
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Cited by (0)
Thomas A. Farley was an employee of the Department of Community Health Sciences, Tulane University School of Public Health and Tropical Medicine, when this research was completed.
Mehul A. Dalal was an employee of the Robert Wood Johnson Clinical Scholars Program, Yale University School of Medicine, when this research was completed.
Farzad Mostashari and Thomas R. Frieden were employees of the New York City Department of Health and Mental Hygiene when this research was completed.