Transcript
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The Power of Prevention:
Rhymes to Remember
Florida State University
College of MedicineFebruary 10, 2011
Steven H. Woolf, MD, MPH, FACPM
Department of Family Medicine, Centeron Human Needs
Virginia Commonwealth University
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Categories of Prevention
Primary prevention
Secondary prevention
Tertiary prevention
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Clinical Preventive Services
Screening tests
Counseling interventions
Immunizations
Chemoprophylaxis
Community Preventive Services
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Leading Causes of Death
Tobacco use
Diet
Physical inactivity
Problem drinking
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Social determinantsof health
Primary prevention Secondary
preventionTertiary
prevention
Determinants of Population Health
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Role of CliniciansRationale for clinician involvement
Credibility and imprimatur of adviceIntegration with primary care and medical history
ImpedimentsBenefits of counseling depend on intensity
Lack of time, skills, staff, reimbursement to offerintensive counseling and ongoing support
Practice redesign to offer such services notfeasible in typical US primary care practices
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A New Decade Dawns
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Past as Prologue
"History doesn't repeat itself,but it does rhyme."
Mark Twain
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Rhymes: What Hasn’t Changed
Deaths and injuries from preventable
causes continue
Unhealthy behaviors persist
Many lethal diseases (e.g., lung, ovarian,pancreatic cancer) remain unpreventable
Too much is wasted on dubious tests and
scans
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Rhymes: What Hasn’t Changed
The argument for evidence-based
medicine persists
The need for systematic methods to
critique evidence persistsGood evidence on effectiveness is sparse
Experts continue to challenge evidence
Advocates continue to dismiss harms
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“This is How Rationing Begins”
“This is how rationing begins…This is whathe had warned about.”
Rep. Marsha Blackburn (R-Tenn.)
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Why not screen?
Assuming monetary costs are not the
issue…
If there is even the slightest possibility ofbenefit, albeit unproved, why shouldn’t
patients be offered screening and the
chance to avoid adverse outcomes fromundetected disease?
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Schwartz et al. JAMA 2004;291(1):71-8.
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Harms of Screening
Test procedure
Anxiety and labeling effects
False-positive results
Harms of treatment
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Elmore et al., 19989762 mammograms over 10 years
24% = false positives49% cumulative probability over 10 years
Consequences of false positives
– 870 outpatient appointments – 539 diagnostic mammograms
– 186 ultrasound examinations
– 188 biopsies
19% probability of biopsy over 10 years
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Rhymes: What Hasn’t Changed
The U.S. Preventive Services Task Force
and the Community Task Force onPreventive Services
– Philosophy and mission
– Composition
– Rules (hierarchy) of evidence
– Focus on science – Vulnerability to criticism
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Rhymes: What Hasn’t Changed
The Mammogram Wars
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“Many members of the public were confused by the report.”
“‘It was a shame that the report was ever published, and Ithink the public ought to ignore the findings,’ said Dr.
Charles R. Smart, chief of the early detection branch,division of cancer prevention and control, of the NationalCancer Institute in Bethesda, Md.”
New York Times, May 4, 1987
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New mammography questions raised
Mammography Review Shatters the Status Quo
Doubts About Its Value Alarm Many
Dispute Builds Over Value of
Mammography
Circling the Mammography
Wagons
Expert Panel Cites Doubts On Mammogram's
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Rhymes: What Hasn’t Changed
Special interests,
profit motivesGovernment intrusion
The need to insulate
science from politics
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Rhymes: What Hasn’t Changed
Disparities, inequity, “reverse targeting”
Misplaced priorities
2%
98%
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International Symposium on Preventive Services in Primary Care, Hotel l’Esterel,
Quebec, October 4-7, 1987
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What Has Changed in 25
Years?
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What Has Changed?
Acceptance of prevention: from fringe idea
to national stageRecession, health care reform, and
leverage of prevention
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What Has Changed?
The evidence base for prevention
Accepted core of effective preventive services – Screening tests
– Clinical expectation to address modifiable risk factors
– Effective public health and population-basedstrategies
Name recognition of USPSTF and Community
Task ForcesDangers to independent scientific analysis
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What Has Changed?
Attempts at prioritization
Understanding of implementationchallenges
QALY S d if Utili ti W I d
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QALYs Saved if Utilization Were Increased
Above Current LevelsService % Currently Receiving QALYs saved if use
increased to 90%
Tobacco Cessation Counseling 35% 1.3 million
Colorectal Cancer Screening 25% 340,000
Influenza immunization 36% and 65% 110,000
Breast cancer screening 68% 91,000
Cervical cancer screening 79% 29,000
Chlamydia Screening 40% 19,000
Pneumococcal immunization 56% 16,000
Cholesterol screening 87% 12,000
Hypertension screening 90% 0
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What Has Changed?
The “information age”: the good and bad
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What Has Changed?What’s in:
– New screeningtechnologies
– Genomics and
personalized medicine
What’s out:
– Hormone replacement
therapy
– “Preventative”
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A New Way of Thinking About
Preventive Medicine
It’s not aboutcolonoscopies and
mammograms
It’s not about
“exerciseprescriptions”
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Beyond the Clinical Setting
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Socioecological Model
From: The Future of the Public's Health (IOM 2003).
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The Obesity PlayersCommunity
organizations
Health care
Public health
Worksites
SchoolsMedia and advertising
Retailers
Built environment
Supermarkets
Restaurants
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The Problem of Silos
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Clinical-Community Collaboration
Clinical settingsPublic health and
community
organizations
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Source: Davis RM. Am J Prev Med 2005;29:154-7.
The Medicine-Public Health Divide
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The do campaign – workplace signs
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Sample ads – in stores, billboards, etc.
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Physical environment influences behavior
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Social Determinants of Health
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Source: VCU Center on Human Needs: http://www.societaldistress.org/Content.aspx?ID=79
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Health in All PoliciesEducation
JobsIncome
Environment
Transportation
Housing
Agriculture
ImmigrationLand use and zoning
Neighborhood
developmentCrime and safety
Communication
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Communication
Opportunities and Expectations A rapt audience for prevention
– Elected officials, CEOs, insurers – Health care professionals
– Public health and community organizations
– The public, patients
– Media
– Commercial interestsComplex messages to deliver
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Complex Messages To Deliver Screening can save lives, but harms can
outweigh benefitsObesity is a dire public health problem, but
evidence is lacking for physicians to counsel
A child can be harmed by vaccines, but childrenin general benefit from herd immunity
Preventing diseases doesn’t necessarily save
money, but it offers good economic value
Communication:
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Communication:
Science vs. AgendasPatients and the public want…
– More, not less (“rationing”) – Tests, not “talk”
– Certainty: what to do and not do, and why
– No risk, and to ignore risks
– Simple messages: the complex as “sound
bites”
Communication:
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Communication:
Science vs. Agendas
Commercial interests
– Profits & power – Countermarketing
Elected officials
– Votes
– Campaigndonations
– Diseases ofpersonal interest
Government officials,
agency heads – Inertia
– Bureaucracy
Media – 24-hour news
cycle, ratings,
inpatient audience
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