Preventive care in adults: Strategies for prioritization and delivery
- Anthony J Viera, MD, MPH
Anthony J Viera, MD, MPH
- Professor of Family Medicine
- University of North Carolina School of Medicine
Quality healthcare for individuals includes two fundamental elements: appropriate treatment for current illness and appropriate preventive care to attempt to lessen future health decline. Preventive health care is an important aspect of medical practice, leading to significant improvements in overall health in the United States .
Several complex issues are involved in providing effective preventive care. Clinicians need to prioritize and decide which of the many available preventive services to recommend and which to discourage to prevent harm from inappropriate tests or interventions. Clinicians also must find a way to deliver preventive services efficiently within the context of a busy clinical practice.
This topic will discuss the approach to prevention and how to prioritize preventive services and interventions. Basic epidemiologic principles of screening and recommendations for primary prevention of conditions that cause an important burden of suffering in adults are presented elsewhere. (See "Evidence-based approach to prevention" and "Preventive care in adults: Recommendations".)
PRIORITIZING PREVENTIVE SERVICES
Preventive services should focus on priority health problems and effective interventions (table 1). Rather than performing a standardized comprehensive examination ("full physical") on all patients, clinicians should individualize screening and prevention interventions to maximize value, which encompasses the tradeoffs between benefits, harms, and costs [2,3].
Factors to consider — Priority services may differ from patient to patient depending upon age, sex, and other risk factors. The effects of recommend preventive care interventions on longevity or quality of life vary over a 100-fold and the potential beneficial effect of any one intervention on an individual patient varies with his or her lifestyle habits, medical and family history, and other risk factors . Available tools to help clinicians prioritize preventive services include:To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Centers for Disease Control and Prevention (CDC). Ten great public health achievements--United States, 1900-1999. MMWR Morb Mortal Wkly Rep 1999; 48:241.
- Saini SD, van Hees F, Vijan S. Smarter screening for cancer: possibilities and challenges of personalization. JAMA 2014; 312:2211.
- Harris RP, Wilt TJ, Qaseem A, High Value Care Task Force of the American College of Physicians. A value framework for cancer screening: advice for high-value care from the American College of Physicians. Ann Intern Med 2015; 162:712.
- Taksler GB, Keshner M, Fagerlin A, et al. Personalized estimates of benefit from preventive care guidelines: a proof of concept. Ann Intern Med 2013; 159:161.
- Maciosek MV, Coffield AB, Edwards NM, et al. Priorities among effective clinical preventive services: results of a systematic review and analysis. Am J Prev Med 2006; 31:52.
- Lipitz-Snyderman A, Bach PB. Overuse of health care services: when less is more … more or less. JAMA Intern Med 2013; 173:1277.
- Zipkin DA, Umscheid CA, Keating NL, et al. Evidence-based risk communication: a systematic review. Ann Intern Med 2014; 161:270.
- Hoffmann TC, Del Mar C. Patients' expectations of the benefits and harms of treatments, screening, and tests: a systematic review. JAMA Intern Med 2015; 175:274.
- www.uspreventiveservicestaskforce.org/adultrec.htm (Accessed on July 01, 2014).
- Woolf SH, Harris R. The harms of screening: new attention to an old concern. JAMA 2012; 307:565.
- Welch HG, Black WC. Overdiagnosis in cancer. J Natl Cancer Inst 2010; 102:605.
- Lansdorp-Vogelaar I, Gulati R, Mariotto AB, et al. Personalizing age of cancer screening cessation based on comorbid conditions: model estimates of harms and benefits. Ann Intern Med 2014; 161:104.
- Gross CP. Cancer screening in older persons: a new age of wonder. JAMA Intern Med 2014; 174:1565.
- Royce TJ, Hendrix LH, Stokes WA, et al. Cancer screening rates in individuals with different life expectancies. JAMA Intern Med 2014; 174:1558.
- Himmelstein DU, Phillips RS. Should We Abandon Routine Visits? There Is Little Evidence for or Against. Ann Intern Med 2016; 164:498.
- Ponka D. The periodic health examination in adults. CMAJ 2014; 186:1245.
- Ruffin MT, Gorenflo DW, Woodman B. Predictors of screening for breast, cervical, colorectal, and prostatic cancer among community-based primary care practices. J Am Board Fam Pract 2000; 13:1.
- Boulware LE, Marinopoulos S, Phillips KA, et al. Systematic review: the value of the periodic health evaluation. Ann Intern Med 2007; 146:289.
- Fenton JJ, Cai Y, Weiss NS, et al. Delivery of cancer screening: how important is the preventive health examination? Arch Intern Med 2007; 167:580.
- Atlas SJ, Grant RW, Ferris TG, et al. Patient-physician connectedness and quality of primary care. Ann Intern Med 2009; 150:325.
- Ferrante JM, Lee JH, McCarthy EP, et al. Primary care utilization and colorectal cancer incidence and mortality among Medicare beneficiaries: a population-based, case-control study. Ann Intern Med 2013; 159:437.
- Fisher KJ, Lee JH, Ferrante JM, et al. The effects of primary care on breast cancer mortality and incidence among Medicare beneficiaries. Cancer 2013; 119:2964.
- Laine C. The annual physical examination: needless ritual or necessary routine? Ann Intern Med 2002; 136:701.
- Si S, Moss JR, Sullivan TR, et al. Effectiveness of general practice-based health checks: a systematic review and meta-analysis. Br J Gen Pract 2014; 64:e47.
- Krogsbøll LT, Jørgensen KJ, Grønhøj Larsen C, Gøtzsche PC. General health checks in adults for reducing morbidity and mortality from disease. Cochrane Database Syst Rev 2012; 10:CD009009.
- Torke AM, Schwartz PH, Holtz LR, et al. Older adults and forgoing cancer screening: "I think it would be strange". JAMA Intern Med 2013; 173:526.
- Lee SJ, Boscardin WJ, Stijacic-Cenzer I, et al. Time lag to benefit after screening for breast and colorectal cancer: meta-analysis of survival data from the United States, Sweden, United Kingdom, and Denmark. BMJ 2013; 346:e8441.
- Stone EG, Morton SC, Hulscher ME, et al. Interventions that increase use of adult immunization and cancer screening services: a meta-analysis. Ann Intern Med 2002; 136:641.
- Szilagyi P, Vann J, Bordley C, et al. Interventions aimed at improving immunization rates. Cochrane Database Syst Rev 2002; :CD003941.
- Sequist TD, Zaslavsky AM, Marshall R, et al. Patient and physician reminders to promote colorectal cancer screening: a randomized controlled trial. Arch Intern Med 2009; 169:364.
- Ghorob A, Bodenheimer T. Sharing the care to improve access to primary care. N Engl J Med 2012; 366:1955.