Fewer Than Half of Americans Receive Some of the Most Valuable Health Care Services: Colorectal cancer screening and tobacco counseling top the list
Fewer than half of all Americans receive some of the most valuable preventive health services available, according to a new study released today by the nonprofit group Partnership for Prevention. The Centers for Disease Control and Prevention sponsored the study.
The study prioritized 30 preventive health services recommended for average-risk patients based on the services’ health benefits and cost effectiveness. Several services ranked high on the list, yet currently reach less than half of Americans: tobacco cessation counseling for adults, screening older adults for undetected vision impairments, screening adults 50+ years for colorectal cancer, screening young women for chlamydia, screening and counseling adults for problem drinking, and vaccinating older adults against pneumococcal disease.
"The study will help decision makers in the healthcare industry prioritize the preventive services that not only save the most lives, but also the most money in the long run," said CDC Director Dr. Jeffrey P. Koplan. "These gaps in care should be closed for the benefit of everyone."
Two articles about the study appear in the July 2001 issue of the American Journal of Preventive Medicine.
Counseling adolescents to avoid or quit using tobacco products and counseling them to avoid alcohol and drugs were two additional high-ranking, low-delivery services. Limited information about the effect of counseling on adolescents’ behavior is available. However, this analysis found that fewer than 10 of every 10,000 teenagers would have to follow the advice of their doctors for these two services to produce substantial health benefits and net savings.
Five other top-ranking services -- childhood vaccines, cervical cancer screening, hypertension screening, cholesterol screening and vaccinating older adults against influenza -- are currently delivered to more than half of Americans.
The authors caution, however, that gaps in the delivery of these services remain and continued efforts are needed to improve delivery levels for some groups.
For example, in 1999, 79 percent of women reported having received cervical cancer screening (Pap test) within the past three years, yet only 69 percent of women living in poverty received the test. Sixty-four percent of adults 65 and older received the influenza vaccine in 1998, while just 46 percent of older adults who are African American received it.
The study examined 30 clinical preventive services recommended for average-risk patients by the U.S. Preventive Services Task Force (USPSTF), an independent panel of experts sponsored by the federal Agency for Healthcare Research and Quality. USPSTF recommendations are considered the gold standard among recommendations for preventive care. However, decision-makers wishing to improve delivery of preventive services face competing demands for finite resources and need additional information about which services provide the most benefits to the populations they serve.
This is the first and most comprehensive study to fully integrate the cost and impact of a specific disease or injury with the effectiveness and cost of services to prevent that disease or injury.
Among the study’s key findings:
Tobacco cessation counseling, including treatment with nicotine replacement, is effective and addresses the nation’s leading killer – heart disease -- yet a third of smokers enrolled in managed care did not receive advice to quit from their providers in 1999. This portion is expected to be even higher among all smokers (not just those enrolled in managed care). If counseling were delivered to all smokers on a regular basis, approximately 70,000 deaths could be prevented in one year. Preventing adolescents from ever smoking could save even more lives.
Vision screening by primary care providers would help eliminate the high prevalence of correctable poor vision among the elderly. A third of adults 65 and older have under-corrected vision and would benefit from screening. Poor vision reduces quality of life and is a possible cause of falls that result in hip fractures.
Regular screening for colorectal cancer, the second leading cause of cancer death, could prevent at least a third of deaths from the disease. Yet in 1999 only 21 percent of those 50 and older reported having had a fecal occult blood test (FOBT) in the last year, and only 34 percent reported having had a sigmoidoscopy or colonoscopy in the previous five years. If screening with FOBT and sigmoidoscopy were delivered to all persons 50 and older on a regular basis, many lives could be prevented in one year.
Screening for chlamydia among sexually active women 15-25 years would help reduce this sexually transmitted disease, the most commonly reported infectious disease in the United States. It is estimated that 3 million new cases occur each year. Fewer than one in five women are currently screened. Initial infections may have no symptoms, but without treatment, 40 percent of women develop pelvic inflammatory disease, which can cause infertility.
The pneumococcal vaccine, which is effective for at least 10 years, would help reduce hospitalizations and premature death due to invasive pneumococcal disease (a bacterial infection) among the elderly, yet more than half of people 65 and older have not received it.
Finally, few providers discuss alcohol use with their patients. Screening and counseling for problem drinking can identify patients whose alcohol use is excessive. Brief counseling following a few screening questions has been shown to reduce alcohol consumption by some patients. Alcohol abuse causes 100,000 premature deaths annually in the U.S. Preventing adolescents from abusing alcohol could result in immediate reductions in injuries and significant financial benefits.
The ranking of preventive services was based on two dimensions. The first was the portion of disease, injury, and premature death prevented if the service were delivered to all persons in the target population on a regular basis.
The second dimension was cost effectiveness, measured as the net cost of the preventive service divided by the service’s health benefits. Net costs are the resources used in providing the service less the resources saved by avoiding disease or injury (e.g., avoided hospital costs).
Scores for each dimension were added, and the services were ranked in descending order. (The only service receiving the highest possible score on both dimensions was childhood vaccines.) Finally, the authors identified which highest ranked services had the lowest delivery rates nationally.
To read the full text of the studies and related commentary go to AJPM online at www.elsevier.com/locate/ajpmonline. For more information about CDC and its work in disease prevention, visit www.cdc.gov.
The Centers for Disease Control and Prevention protects people’s health and safety by preventing and controlling diseases and injuries; enhances health decisions by providing credible information on critical health issues; and promotes healthy living through strong partnerships with local, national and international organizations.