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Clinical Preventive Medicine in Primary Care: Background and Practice: 1. Rationale and Current Preventive Practices

  • Donald D. Hensrud
    Correspondence
    Address reprint requests and correspondence to Donald D. Hensrud, MD, MPH, Division of Preventive and Occupational Medicine, Mayo Clinic Rochester, 200 First St SW, Rochester, MN 55905
    Affiliations
    Division of Preventive and Occupational Medicine and Internal Medicine and Division of Endocrinology, Metabolism, Nutrition and Internal Medicine, Mayo Clinic Rochester, Rochester, Minn
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      Impressive evidence supports the value of clinical preventive medicine, defined as the maintenance and promotion of health and the reduction of risk factors that result in injury and disease. Primary prevention activities deter the occurrence of a disease or adverse event, eg, smoking cessation. Secondary prevention (screening) is early detection of a disease or condition in an asymptomatic stage so treatment delays or blocks occurrence of symptoms, eg, mammographic detection of breast cancer. Tertiary prevention attempts to not allow adverse consequences of existing clinical disease, eg, cardiac rehabilitation to prevent the recurrence of a myocardial infarction. Preventive services have decreased morbidity and mortality from both acute and chronic conditions. However, these services are underutilized for numerous reasons. Barriers to their use include physician, patient, and health system factors. The traditional disease/treatment model should be modified to incorporate more preventive services. The subsequent 2 parts of this review will discuss suggestions for integrating primary preventive services and screening into primary care practice.
      The doctor of the future will give no medicine, but will interest his patients in the care of the human frame, in diet, and in the cause and prevention of disease.Thomas A. Edison
      To some degree, these words by Edison are echoing in the halls of medicine long after they were first conceived. In recent years there has been heightened interest in the prevention of disease, and preventive medicine is assuming an increasingly important role in promoting and maintaining health as evidence supporting its intuitive rationale has accumulated. Although therapeutic medicine has made great strides in this century, it has become clear that the potential for preventive care to improve the health of the population is also great.
      Preventive care services can be delivered in a variety of ways, such as through public health programs or during a visit to a physician. On average, 3 of every 4 people in the United States see a physician each year, and the majority of visits are to primary care practitioners who are an important source of health care information.
      • Ries P
      Physician contacts by sociodemographic and health characteristics: United States, 1982-83.
      • David AK
      • Boldt JS
      A study of preventive health attitudes and behaviors in a family practice setting.
      Because health concerns are at the forefront of people's minds during an office encounter where a physician's message can make a powerful, reliable, and credible impression, physician visits provide a unique opportunity to deliver preventive care. Despite this, preventive services are currently underutilized by physicians due, in part, to the way some aspects of clinical medical care are commonly practiced.
      Much of medical practice is based on a disease/treatment model rather than a prevention model in that the predominant focus is on treating existing symptoms and conditions. While few would argue this approach is necessary for acute conditions, there is some question whether this is the most efficient and effective way of delivering preventive care. In the traditional annual periodic health examination, a patient sees a physician and proceeds through a series of steps, including a medical history, physical examination, and laboratory studies that culminate in an assessment and plan of action. The content of this visit has evolved more from the concerns of the examination's advocates at various historical times, rather than any formal process and evaluation.
      • Han PKJ
      Historical changes in the objectives of the periodic health examination.
      The periodic health examination became popular in the 1920s and was endorsed by the American Medical Association after an apparent decrease in mortality was observed in life insurance policy holders who had undergone such an examination.
      • Charap MH
      The periodic health examination; genesis of a myth.
      However, these data were probably confounded by many methodologic problems. A critical analysis of the value of the individual components of the periodic health examination would not occur for more than half a century. Frame and Carlson
      • Frame PS
      • Carlson SJ
      A critical review of periodic health screening using specific screening criteria, part 1 : selected diseases of respiratory, cardiovascular, and central nervous systems.
      • Frame PS
      • Carlson SJ
      A critical review of periodic health screening using specific screening criteria, part 2: selected endocrine, metabolic, and gastrointestinal diseases.
      • Frame PS
      • Carlson SJ
      A critical review of periodic health screening using specific screening criteria, part 3: selected diseases of the genitourinary system.
      • Frame PS
      • Carlson SJ
      A critical review of periodic health screening using specific screening criteria, part 4: selected miscellaneous diseases.
      followed by the Canadian Task Force
      • Canadian Task Force on the Periodic Health Examination
      The periodic health examination.
      and later the US Preventive Services Task Force
      • US Preventive Services Task Force
      outlined evidence regarding the relative effectiveness of different preventive interventions. In many cases standard components of the current periodic health examination, such as certain laboratory tests, were found to have little supportive data while potentially valuable interventions, including many areas of health behavior counseling, were not widely utilized.
      A major task, therefore, is to modify the traditional medical model to incorporate more preventive services. Moreover, to effectively practice preventive medicine, information concerning its rationale and clinical application must be available to physicians and other health care providers. This article reviews relevant background information, evidence supporting preventive services, and current preventive practices. The second and third parts of this review will provide suggestions for incorporating clinical preventive medicine into adult primary care practice.

      Types Of Prevention

      Clinical preventive medicine is that part of preventive medicine concerned with the maintenance and promotion of health and the reduction of risk factors that result in injury and disease.
      • Critical issues discussed at preventive medicine summit in Atlanta
      There are 3 main types of preventive medicine (Table 1). Primary prevention can be defined as an action or behavior that does not allow a disease or adverse event to occur. Examples of primary prevention include immunization, smoking cessation, or initiation of an exercise program with the goal of disease prevention. Health promotion activities are included under primary prevention. Secondary prevention is the early detection of a disease or condition in an asymptomatic stage so treatment can delay or block the occurrence of symptoms. Screening for disease such as mammographic detection of breast cancer falls in the category of secondary prevention. Tertiary prevention attempts to deter adverse consequences of existing clinical disease. A cardiac rehabilitation program to prevent the recurrence of a myocardial infarction is an example of tertiary prevention. Tertiary prevention overlaps with conventional medical care in that it can be considered treatment for an established condition.
      Table 1Types of Prevention
      Prevention typeGoal
      Primary preventionDisease does not occur
      Secondary preventionDetection and treatment of asymptomatic disease before symptoms occur
      Tertiary preventionConsequences of existing disease or recurrent disease does not occur
      If primary prevention is successful, the incidence of a disease decreases. In contrast, however, secondary prevention does not necessarily prevent a disease from occurring but rather detects it early enough to allow effective treatment. Similarly, tertiary prevention does not prevent the occurrence of a disease but tries to prevent the complications of established disease.

      Evidence Supporting Prevention

      The leading causes of death in the United States have changed markedly since the beginning of this century (Table 2).
      • Linder FE
      • Grove RD
      • Peters KD
      • Kochanek KD
      • Murphy SL
      Deaths: final data for 1996.
      There has been a shift from acute infectious diseases to chronic diseases. Most of the current leading causes of death from chronic diseases are related to lifestyle factors, including health behaviors. The burden of suffering from the “actual” causes of death, ie, the underlying external (nongenetic) factors that contribute to mortality, have been described (Table 3).
      • McGinnis JM
      • Foege WH
      Actual causes of death in the United States.
      An estimated 400,000 people die each year from tobacco-related illness, while unhealthy nutrition and physical activity patterns account for at least 300,000 deaths. Clearly, many of these deaths could potentially be prevented or delayed through primary prevention activities. At a minimum, some of the diseases resulting from these factors could be diagnosed and treated at an early stage through screening.
      Table 2Leading Causes of Death in the United States in 1900 and 1996
      1900
      Data from Linder and Grove.13
      1996
      Data from Peters et al.14
      Cause%Cause%
      1.Pneumonia/influenza131.Heart disease32
      2.Tuberculosis112.Cancer23
      3.Diarrhea/enteritis83.Cerebrovascular diseases7
      4.Heart disease74.Chronic obstructive lung disease5
      5.Nephritis55.Accidents4
      6.Accidents46.Pneumonia/influenza4
      7.Cerebrovascular disease47.Diabetes mellitus3
      8.Cancer48.Human immunodeficiency virus1
      9.Diseases of infancy39.Suicide1
      10.Diphtheria210.Chronic liver disease1
      * Data from Linder and Grove.
      • Linder FE
      • Grove RD
      Data from Peters et al.
      • Peters KD
      • Kochanek KD
      • Murphy SL
      Deaths: final data for 1996.
      Table 3Actual Causes of Death in the United States in 1990
      Adapted from McGinnis and Foege.'5
      CauseEstimated No. of deaths%of total deaths
      1.Smoking400,00019
      2.Diet/activity patterns300,00014
      3.Alcohol100,0005
      4.Microbial agents90,0004
      5.Toxic agents60,0003
      6.Firearms35,0002
      7.Sexual behavior30,0001
      8.Motor vehicles25,0001
      9.Illicit use of drugs20,000<1
      * Adapted from McGinnis and Foege.'
      • Charap MH
      The periodic health examination; genesis of a myth.
      Some progress has been made over the latter half of this century in decreasing the morbidity and mortality of certain health conditions through prevention. Declines in the incidence of acute infectious diseases secondary to increased delivery of immunizations has been well documented for many illnesses, including measles, mumps, rubella, pertussis, diphtheria, and most recently invasive Haemophilus influenzae.
      • Center for Disease Control and Prevention
      Update: vaccine side effects, adverse reactions, contraindications, and precautions; recommendations of the Advisory Committee on Immunization Practices (ACIP).
      Mortality from stroke has decreased by 60% since the mid-1970s due, in part, to increased detection and control of untreated hypertension.
      • Garraway WM
      • Whisnant JP
      The changing pattern of hypertension and the declining incidence of stroke.
      • Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure
      The sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.
      • Mosterd A
      • D'Agostino RB
      • Silbershalz H
      • et al.
      Trends in the prevalence of hypertension, antihypertensive therapy, and left ventricular hypertrophy from 1950 to 1989.
      More recently, however, stroke incidence appears to have increased in some populations.
      • Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure
      The sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.
      • Brown RD
      • Whisnant JP
      • Sicks JD
      • O'Fallon WM
      • Wiebers DO
      Stroke incidence, prevalence, and survival : secular trends in Rochester, Minnesota, through 1989.
      In addition, although the proportion of individuals with hypertension who are being detected and treated has improved over the past 30 years, a large number of people would benefit from treatment, yet their hypertension remains undetected.
      • Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure
      The sixth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.
      • Mulrow PJ
      Detection and control of hypertension in the population: the United States experience.
      The mortality from coronary heart disease has declined 50% in the past 2 decades.
      Part of this decline may be due to improved treatment from coronary artery bypass graft procedures, coronary care units, and better emergency response services. On the other hand, it was estimated the majority of the early portion of this decline was due to changes in lifestyle, specifically decreased smoking prevalence and serum total cholesterol levels in the general population.
      • Goldman L
      • Cook EF
      The decline in Ischemie heart disease mortality rates: an analysis of the comparative effects of medical interventions and changes in lifestyle.
      More recent the decline in coronary heart disease has continued and is due to both improved treatment and risk factor profiles.
      • Rosamond WD
      • Chambless LE
      • Folsom AR
      • et al.
      Trends in the incidence of myocardial infarction and in mortality due to coronary heart disease, 1987 to 1994.
      • Hunink MG
      • Goldman L
      • Tostcson ANA
      • et al.
      The recent decline in mortality from coronary heart disease, 1980-1990: the effect of secular trends in risk factors and treatment.
      • McGovem PG
      • Pankow JS
      • Shahar E
      • et al.
      Recent trends in acute coronary heart disease: mortality, morbidity, medical care, and risk factors.
      Cancer mortality in the United States increased 6% from 1970 to 1994, and new treatments had little overall effect during this time.
      • Bailar III, JC
      • Gomik HL
      Cancer undefeated.
      Declines in the mortality from some cancers during this period were probably the result of primary (decreased lung cancer mortality in men due to reductions in smoking prevalence) and secondary (decreased cervical cancer mortality in women secondary to increased screening with the Papanicolaou test) prevention activities. Based on this overall lack of decline in cancer mortality, it was suggested the national approach to cancer control should be realigned to emphasize and support prevention much more than current efforts.
      • Bailar III, JC
      • Gomik HL
      Cancer undefeated.
      The associations of certain behaviors and risk factors with specific diseases and injuries have become more clear in recent years. Moreover, there has been increasing recognition of the potential of preventive activities to improve the health of the population. However, what evidence exists that preventive services are effective in decreasing morbidity and mortality and improving the quality of life? In 1975 Frame and Carlson
      • Frame PS
      • Carlson SJ
      A critical review of periodic health screening using specific screening criteria, part 1 : selected diseases of respiratory, cardiovascular, and central nervous systems.
      • Frame PS
      • Carlson SJ
      A critical review of periodic health screening using specific screening criteria, part 2: selected endocrine, metabolic, and gastrointestinal diseases.
      • Frame PS
      • Carlson SJ
      A critical review of periodic health screening using specific screening criteria, part 3: selected diseases of the genitourinary system.
      • Frame PS
      • Carlson SJ
      A critical review of periodic health screening using specific screening criteria, part 4: selected miscellaneous diseases.
      systematically reviewed screening in the periodic health examination with use of specific criteria. They found that many traditional tests and procedures could not be justified, and it was not necessary to perform others annually. They presented a screening flow sheet outlining recommendations and intervals for screening tests. In 1979 the Surgeon General's Report reviewed the state-of-the-art up to that time on health promotion and disease prevention.
      This report outlined a strong case for more attention to disease prevention and health promotion in many different areas. Also, in a 1979 landmark study, the Canadian Task Force on the Periodic Health Examination used specific criteria with regard to the quality of data to evaluate individual components of the periodic health examination.
      • Canadian Task Force on the Periodic Health Examination
      The periodic health examination.
      Similar to the Canadian Task Force, the evidence supporting the clinical effectiveness of preventive services was again reviewed by the US Preventive Services Task Force and published in 1989 in the Guide to Clinical Preventive Services,
      • US Preventive Services Task Force
      which was updated with the publication of the second edition in 1996.
      • US Preventive Services Task Force
      Set criteria were used to evaluate the quality of evidence regarding the effectiveness of screening and counseling interventions to prevent 70 different illnesses and conditions. A major principle finding of the US Task Force was that interventions that address patients' personal health practices are vitally important. Implicit in this is that patients must assume greater responsibility for their own health, and therefore physicians need to be prepared to help them in this effort by providing counseling and appropriate resources.
      Another finding was that clinicians must take every opportunity to deliver preventive services, especially to persons with limited access to care. However, clinicians should be selective in ordering tests and procedures and even providing certain preventive services. Some tests that have traditionally been performed as part of the periodic health examination are of unproven effectiveness. Other tests such as certain screening tests are expensive or could even lead to harm from further diagnostic tests or treatment. By outlining the quality of evidence for different interventions, the Guide to Clinical Preventive Services can help physicians determine, in conjunction with the patient, which screening procedures and counseling services to provide after taking into consideration that patient's profile of risk factors.
      The evidence for the physical examination components of the periodic health examination has been reviewed.
      • Oboler SK
      • LaForce FM
      The periodic physical examination in adults.
      For many routine components there was little supportive evidence. However, no evidence is not the same as negative evidence, and there may be particular individuals who benefit from the discovery of important physical findings despite little evidence of a significant overall effect in a population.
      The effect of patient education and counseling was determined in a meta-analysis of 74 studies.
      • Mullen PD
      • Simons-Morton DG
      • Ramirez G
      • et al.
      A meta-analysis of trials evaluating patient education and counseling for three groups of preventive health behaviors.
      A beneficial effect was found for all behavior groups, including smoking and alcohol misuse, nutrition and weight control, and other preventive behaviors.
      Certain preventive interventions, such as mammographic screening for breast cancer, are cost-effective.
      • Lindfors KK
      • Rosenquist CJ
      The cost-effectiveness of mammographie screening strategies.
      Programs promoting smoking cessation during pregnancy, use of bicycle safety helmets, and immunizations are all estimated to save money—up to $14 for every dollar spent in the case of some immunizations.
      • Salcher D
      • Hull FL
      The weight of an ounce.

      Current Preventive Practices

      Currently, most physicians practice some aspects of preventive medicine although there is wide variability and, in general, preventive medicine is underutilized in most practices. Studies have shown physicians' recommendations for screening tests, immunizations, and health promotion assessment and counseling fall short of meeting expert guidelines.
      • Schwartz JS
      • Lewis CE
      • Clancy C
      • Kinosian MS
      • Radany MH
      • Koplan JP
      Internists' practices in health promotion and disease prevention.
      • Lewis CE
      Disease prevention and health promotion practices of primary care physicians in the United States.
      • McPhee SJ
      • Richard RJ
      • Solkowitz SN
      Performance of cancer screening in a university general internal medicine practice.
      • McPhee SJ
      • Bird JA
      Implementation of cancer prevention guidelines in clinical practice.
      • Taira DA
      • Safran DG
      • Seto TB
      • Rogers WH
      • Tarlov AR
      The relationship between patient income and physician discussion of health risk behaviors.
      Physicians who are younger, residency trained, generalists, subspecialists within their specialty, in a group practice, and experienced with the US Preventive Services Task Force guidelines are more likely to perform recommended preventive services.
      • Schwartz JS
      • Lewis CE
      • Clancy C
      • Kinosian MS
      • Radany MH
      • Koplan JP
      Internists' practices in health promotion and disease prevention.
      • Czaja R
      • McFall SL
      • Wamecke RB
      • Ford L
      • Kaluzny AD
      Preferences of community physicians for cancer screening guidelines.
      • Stange KC
      • Fedirko T
      • Zyzanski SJ
      • et al.
      How do family physicians prioritize delivery of multiple preventive services?.
      In general, community physicians agree with the screening guidelines of the American Cancer Society, and screening practices are increasing.
      1989 survey of physicians' attitudes and practices in early cancer detection.
      • Lane DS
      • Messina CR
      Current perspectives on physician barriers to breast cancer screening.
      In clinical practice screening Pap tests are recommended to patients at relatively high rates.
      • McPhee SJ
      • Richard RJ
      • Solkowitz SN
      Performance of cancer screening in a university general internal medicine practice.
      • Centers for Disease Control and Prevention
      Trends in cancer screening—United States, 1987 and 1992.
      Yet, there is large variability in performing screening tests for colon cancer.
      1989 survey of physicians' attitudes and practices in early cancer detection.
      Mammograms and clinical breast examinations are often not obtained at recommended intervals, although the percentage of women who have received recent screening with mammography and clinical breast examinations is clearly increasing.
      • Centers for Disease Control and Prevention
      Trends in cancer screening—United States, 1987 and 1992.
      • Fox SA
      • Murata PJ
      • Stein JA
      The impact of physician compliance on screening mammography for older women.
      • Centers for Disease Control and Prevention
      Self-reported use of mammography among women aged greater than or equal to 40 years—United States. 1989 and 1995.
      In contrast, some screening tests are performed routinely although they are not indicated.
      • Czaja R
      • McFall SL
      • Wamecke RB
      • Ford L
      • Kaluzny AD
      Preferences of community physicians for cancer screening guidelines.
      • Clasen CM
      • Vemon SW
      • Mullen PD
      • Jackson GL
      A survey of physician beliefs and self-reported practices concerning screening for early detection of cancer.
      and others are performed more frequently than recommended.
      • Woo B
      • Woo B
      • Cook F
      • et al.
      Screening procedures in the asymptomatic adult: comparison of physicians' recommendations, patients' desires, published guidelines, and actual practice.
      There has been an increase in the proportion of physicians who believe that most health-promoting behaviors are important and that physicians should be educating patients about health-related risk factors.
      • Wechsler H
      • Levine S
      • Idelson RK
      • et al.
      The physician's role in health promotion revisited-a survey of primary care practitioners.
      However, assessment of health behaviors and health promotion counseling vary according to the health habit. Most physicians ask about smoking habits, although fewer spend significant time counseling patients to quit.
      • Cummtngs SR
      • Stein MJ
      • Hansen B
      • Richard RJ
      • Gerbert B
      • Coates TJ
      Smoking counseling and preventive medicine: a survey of internists in private practices and a health maintenance organization.
      • Ockene JK
      • Aney J
      • Goldberg RJ
      • Klar JM
      • Williams JW
      A survey of Massachusetts physicians' smoking intervention practices.
      Compared with smoking, fewer physicians address nutrition and exercise (fewer than half in some studies), and a minority assess and counsel patients about seat belt use and sexual activities.
      • Schwartz JS
      • Lewis CE
      • Clancy C
      • Kinosian MS
      • Radany MH
      • Koplan JP
      Internists' practices in health promotion and disease prevention.
      • Lewis CE
      Disease prevention and health promotion practices of primary care physicians in the United States.
      • Gemson DH
      • Colombotos J
      • Elinson J
      • Fordyce J
      • Hynes M
      • Stoneburner R
      Acquired immunodeficiency syndrome prevention.
      • Boekeloo BO
      • Marx ES
      • Kral AH
      • Coughlin SC
      • Bowman M
      • Rabin DL
      Frequency and thoroughness of STD/HIV risk assessment by physicians in a high-risk metropolitan area.
      • Lewis CE
      • Clancy C
      • Leake B
      • Schwartz JS
      The counseling practices of internists.
      Immunizations are generally underrecommended to eligible patients; usually fewer than half receive appropriate advice.
      • Lewis CE
      Disease prevention and health promotion practices of primary care physicians in the United States.
      Studies looking at the amount of preventive care received by the patient, as opposed to that recommended by the physician, show even less preventive care actually delivered, particularly among the elderly.
      • Kottke TE
      • Solberg LI
      • Brekke ML
      • Cabrera A
      • Marquez MA
      Delivery rates for preventive services in 44 midwestem clinics.
      • Lurie N
      • Manning WG
      • Peterson C
      • Goldberg GA
      • Phelps CA
      • Li Hard L
      Preventive care: do we practice what we preach?.
      • Bergman-Evans B
      • Walker SN
      The prevalence of clinical preventive services utilization by older women.
      There are various reasons why preventive medicine is not more widely practiced. These include physician barriers, patient barriers, and health system barriers (Table 4).
      • Frame PS
      Health maintenance in clinical practice: strategies and barriers.
      More physicians believe that preventive services are important than actually recommend them in their practice.
      1989 survey of physicians' attitudes and practices in early cancer detection.
      • Cummtngs SR
      • Stein MJ
      • Hansen B
      • Richard RJ
      • Gerbert B
      • Coates TJ
      Smoking counseling and preventive medicine: a survey of internists in private practices and a health maintenance organization.
      In addition to the factors in Table 4, this may be due to a lack of confidence in the ability to counsel and change patient behavior, perception that patients will not likely follow recommendations, or views that promoting preventive medicine is outside the role of physicians.
      • Becker MH
      • Janz NK
      Practicing health promotion: the doctor's dilemma.
      Table 4Barriers to Clinical Preventive Medicine
      Adapted from Frame57 with permission.
      • Physician barriers
        • 1.
          Knowledge
        • 2.
          Uncertainty about conflicting recommendations
        • 3.
          Uncertainty about the value of tests or interventions
        • 4.
          Disorganized medical records
        • 5.
          Delayed and indirect gratification from screening
        • 6.
          Lack of time
        • 7.
          Attitudes and personal characteristics
      • Patient barriers
        • 1.
          Ignorance of benefits
        • 2.
          Doubts about the physician's ability to detect a hidden disease
        • 3.
          Cost of procedures
        • 4.
          Discomfort
        • 5.
          A conscious or unconscious desire not to change unhealthy habits
        • 6.
          Social and cultural norms
      • Health system barriers
        • 1.
          Inadequate amount and system of reimbursement (see Table 5)
        • 2.
          Lack of health insurance
        • 3.
          Population mobility
        • 4.
          Patients with multiple physicians
        • 5.
          Categorical, sporadic screening programs such as health fairs
        • 6.
          Inadequate information systems
        • 7.
          Lack of specific preventive service systems
      * Adapted from Frame
      • Frame PS
      Health maintenance in clinical practice: strategies and barriers.
      with permission.
      Physicians' attitudes and personal habits affect the likelihood of counseling their patients in areas of health promotion. Physicians, in general, have relatively favorable health habits. As a group they exercise more
      • Hensrud DD
      • Spraflta JM
      • Connett J
      • Leon AS
      Physical activity in Minnesota physicians.
      and smoke less
      • Hensrud DD
      • Sprafka JM
      The smoking habits of Minnesota physicians.
      compared with the general population, and those with favorable health habits are more likely to recommend changes in these areas to their patients.
      • Lewis CE
      • Clancy C
      • Leake B
      • Schwartz JS
      The counseling practices of internists.
      • Wells KB
      • Lewis CE
      • Leake B
      • Ware Jr, JE
      Do physicians preach whai they practice? a study of physicians' health habits and counseling practices.
      • Lewis CE
      • Wells KB
      • Ware JB
      A modelfor predicting the counseling practices of physicians.
      Moreover, physicians who follow immunization and screening recommendations are more likely to recommend these preventive practices to their patients.
      • Schwartz JS
      • Lewis CE
      • Clancy C
      • Kinosian MS
      • Radany MH
      • Koplan JP
      Internists' practices in health promotion and disease prevention.
      Some of these personal habits may be responsible for the decreased mortality observed in physicians compared with the general population.
      • Steering Committee of the Physicians' Health Study Research Group
      Final report on the aspirin component of the ongoing Physicians Health Study.
      Patient income and gender differences may also affect who receives preventive services.
      • Clasen CM
      • Vemon SW
      • Mullen PD
      • Jackson GL
      A survey of physician beliefs and self-reported practices concerning screening for early detection of cancer.
      • Osborn EH
      • Bird JA
      • McPhee SJ
      • et al.
      Cancer screening by primary care physicians: can we explain the differences?.
      Physicians are less likely to discuss diet and exercise with low-income patients and less likely to discuss smoking with high-income patients.
      • Taira DA
      • Safran DG
      • Seto TB
      • Rogers WH
      • Tarlov AR
      The relationship between patient income and physician discussion of health risk behaviors.
      Female physicians are more likely than their male counterparts to recommend screening mammography and Pap tests for their female patients.
      • Lurie N
      • Stater J
      • McGovem P
      • et al.
      Preventive care for women: does the sex of the physician matter?.
      This may be, in part, because female physicians report being more comfortable than male physicians in obtaining Pap tests and performing breast examinations.
      • Lurie N
      • Margolis K
      • McGovem PC
      • Mink P
      Physician self-report of comfort and skill in providing preventive care to patients of the opposite sex.
      The public has certain misconceptions concerning prevention. Some people believe that the more tests that are performed and the more sophisticated these tests are, the greater will be the likelihood of preventing disease. For example, electron-beam computed tomography to quantify coronary calcification and screen for coronary heart disease has become popular, and advertising for this test may be contributing to a perception of well-established efficacy.
      Although this test can be useful in case finding under certain circumstances, the evidence at this time does not support routine screening.
      • Prigent FM
      • Steingan RM
      Clinical value of electron-beam computed tomography in the diagnosis and prognosis of coronary artery disease.
      • Taylor AJ
      • O'Malley PG
      Self-referral of patients for electron-beam computed tomography to screen for coronary artery disease.
      Moreover, there are potential negative consequences of screening, including false-positive and false-negative test results.
      • Marshalt KG
      Prevention: how much harm? how much benefit? 3. physical, psychological and social harm.
      The perception of “the more screening tests, the better” is coupled with the belief that technology may greatly enhance prevention. There is a general lack of perspective about the relative importance of preventive interventions. The public can be quick to embrace dietary supplements, miracle diets, sophisticated screening tests, and certain alternative preventive practices without documented benefit, yet often ignore basic health behaviors such as following a prudent diet, obtaining regular exercise, and abstaining from tobacco. Evidence for this is found in the visible and widespread advertising and billions of dollars spent each year for unproven products and the relatively low prevalence of healthy diet (low in saturated fat and animal products and high in plant products, particularly fruits and vegetables) and physical activity patterns among the general population. Less than 1 in 3 adults consumes the recommended 5 servings of fruits and vegetables daily,
      • Krebs-Smith SM
      • Cook A
      • Subar AF
      • Cleveland H
      • Friday J
      US adults' fruit and vegetable intakes, 1989 to 1991: a revised baseline for the Healthy People 2000 objective.
      60% of the US population obtains no regular physical activity,
      • Centers for Disease Control and Prevention
      and 23% of the population smokes cigarettes.
      • Centers for Disease Control and Prevention
      State-specific prevalence among adults of current cigarette smoking and smokeless tobacco use and per capita tax-paid sales of cigarettes-United States, 1997.
      Undergoing regular screening tests or changing health habits requires an effort on the part of the patient, who may not be willing to do this if it is costly or uncomfortable, or if the patient is not convinced these measures are beneficial. Beneficial changes in the prevalence of some risk behaviors in the general population, such as smoking, have occurred very slowly, attesting to the difficulty in making sustained health behavior changes.
      Reimbursement for medical care can have a powerful influence on clinical practice, including preventive care. Currently, reimbursement for preventive services varies but is generally poor, particularly reimbursement for health promotion activities. Yet, evidence suggests that providing preventive services for Medicare beneficiaries would result in modest health benefit with no additional cost.
      • Burton LC
      • Steinwachs DM
      • German PS
      • et al.
      Preventive services for the elderly: would coverage affect utilization and costs under medicare?.
      On the other hand, the cost to society could be substantial if some interventions were fully utilized, such as screening mammography in young women.
      • Eddy DM
      • HasseibLad V
      • McGivney W
      • Hendec W
      The value of mammography screening in women under age 50 years.
      This emphasizes the need for careful evaluation of the evidence for effectiveness and data regarding cost prior to recommending routine screening tests.
      There may be other reasons for the low level of reimbursement for preventive services (Table 5). First, outcome data documenting the effectiveness of some preventive services may be lacking. Good evidence links certain risk factors with specific diseases. But it is more difficult to document that (1) changes in risk factors or disease prevalence can be attained through preventive service programs, (2) a decrease in risk factors or disease translates into decreases in morbidity and mortality, and (3) these results can be achieved in a cost-effective manner. For example, although we know that wearing seat belts saves lives, it is more difficult to prove that a counseling session by a physician that convinces some patients to wear their seat belts is both cost-effective and lifesaving. Moreover, success in prevention is a nonevent. It is much easier to recognize and document an antibiotic cure for a specific infectious disease than a premature myocardial infarction that never occurred because a health professional convinced a patient to change his or her diet and exercise habits. In addition, many benefits of preventive medicine are realized only after a long period of time and therefore require an investment in the future. Insurance companies who issue policies that are not continued over a long period may be reluctant to reimburse for preventive services because this requires an investment up front, while the dividends may be realized long after cessation of the insurance policy. This may also apply to companies who may not employ workers for a long period of time.
      Table 5Potential Reasons for Lack of Reimbursement for Preventive Services
      • Increased absolute costs
      • Lack of proven outcome data because of difficulty in demonstrating
        • Decreases in risk factors or disease prevalence
        • Decreases in morbidity and mortality
        • Cost-effectiveness
      • Success in prevention is a “nonevent” and difficult to document
      • Benefits of prevention are realized only after a long time
        • Disincentive for insurance reimbursement short term
        • Disincentive for employer coverage of short-term employees
      Other barriers to the implementation of preventive services have been described, many of which relate to the health care system yet are expressed as lack of time.
      • Rafferty M
      Prevention services in primary care: taking time, setting priorities.
      • Kottke TE
      • Brekke ML
      • Solberg LI
      Making “time” for preventive services.
      For example, most current health care systems emphasize urgency of acute problems over severity of chronic problems that could possibly be prevented. Moreover, physicians are encouraged to respond to current problems rather than initiate preventive actions. Finally, political factors could be added to the list in Table 4, because in many cases politics helps determine overall funding for preventive services. It has been estimated that less than 5% of total annual health care expenditures in the United States is spent on prevention.
      • Centers for Disease Control and Prevention
      Estimated national spending on prevention-United States, 1988.
      Managed care is continuing to grow. Along with this are new opportunities for incorporating preventive practices into managed care systems.
      • Harris JR
      • Gordon RL
      • White KE
      • et al.
      Prevention and managed care: opportunities for managed care organizations, purchasers of health care, and public health agencies.
      Improvement in various outcome measures has been reported from implementation of primary and secondary preventive services in a large health maintenance organization.
      • Thompson RS
      • Taplin SH
      • McAfee TA
      • et al.
      Primary and secondary prevention services in clinical practice.
      In some managed care organizations, guidelines for the appropriate use of resources to diagnose, treat, and prevent diseases are being developed that may have a strong influence on the way clinical medicine is practiced. One potential benefit of this is decreased expenses because of ordering fewer tests that may not be cost-effective on a population-wide basis, ie, eliminating inefficient screening tests. As local guidelines are developed, it will be important to recognize national guidelines from the US Preventive Services Task Force and other credible sources regarding health promotion and screening.
      • US Preventive Services Task Force
      • US Department of Health and Human Services
      National Guideline Clearinghouse.
      It will also be important to remain flexible and recognize the value of modifying screening recommendations to individual patients based on their risk status, ie, case finding. These issues underscore the importance of performing outcomes research to document the effectiveness of preventive services.
      It follows from the previous discussion that changes are necessary in a number of areas to help break down barriers and improve the practice of preventive medicine. Changes in the health care system will be necessary to increase preventive services on a population-wide basis.
      • Leaf A
      Preventive medicine for our ailing health care system.
      Covering basic preventive services by providing appropriate reimbursement could have a major effect on reducing morbidity and mortality from many diseases. Education is a necessary and important first step for patients, physicians, and other health care providers. However, knowledge, by itself, does not translate into behavior change. Office-based strategies to translate knowledge into action may help promote beneficial changes in health behaviors. Once the value of preventive services is acknowledged and supported, then programs and systems to implement these services can be initiated. Some suggestions for implementation will be described in the next article in this review.

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