1. Who Cares About Preventive Medicine?
Douglas B. Kamerow, MD, MPH
Senior Scholar in Residence
Robert Graham Center for Primary Care Policy Studies
and
Professor of Family Medicine
Georgetown University
29 September 2016

2. Overview How do we tell what is important? Does prevention work?
Does prevention save money?
How good a job are we doing?
What are the barriers?
Take-home messages for policy and clinic
[optional] digression on e-cigarettes

3. What Do Doctors Do?

4. How Do We Know What to Teach in Residency?
(In other words, what is important to learn?)

5. Poll: What is the Leading Cause of Death?
A: Heart disease
B: Stroke/cerebrovascular disease
C: Cancer
D: Chronic lung disease
E: Other

6. What is the Leading Cause of Death?
A: Heart disease
B: Stroke/cerebrovascular disease
C: Cancer
D: Chronic lung disease
E: Other

7. 10 Leading Causes of Death, US, 2014
Heart Disease ,348
Cancer ,699 Chronic Lung Disease ,101
Unintentional Injuries ,053
Stroke ,103
Alzheimer’s Disease ,541
Diabetes ,488
Influenza and Pneumonia ,227
Kidney Disease ,146
Suicide ,773 Total for Top ,938,479
Total Deaths in 2014: 2,626,418

8. Costs of the Leading Causes of Death*
Heart conditions $76 billion
Trauma disorders $72 billion
Cancer $70 billion
Mental disorders $56 billion
Asthma and chronic lung disease $54 billion
High blood pressure $42 billion
Type 2 diabetes $34 billion
Osteoarthritis/other joint diseases $34 billion
Back problems $32 billion
Normal childbirth $32 billion
*2005 direct medical costs

9. Years of Potential Life Lost, 2014*
Cancer ,416,968
Unintentional Injuries ,146,798 Heart Disease ,130,959
Suicide ,206,515
Perinatal deaths ,645 Homicide ,476
Chronic lung disease ,470
Liver disease ,980
Diabetes ,659
Stroke ,590
*Before age 75

10. Risk Factors for the Leading Causes of Death
Heart Disease Tobacco, Obesity, BP, Cholesterol
Cancer Tobacco, Diet, Alcohol, Environmental Exposures
Stroke Tobacco, BP, Cholesterol
Unintentional Injuries Safety Belts, Alcohol, Home Hazards
Chronic Lung Disease Tobacco, Environmental Exposure

11. Risk Factors for the Leading Causes of Death
Heart Disease Tobacco, Obesity, BP, Cholesterol
Cancer Tobacco, Diet, Alcohol, Environmental Exposures
Stroke Tobacco, BP, Cholesterol
Unintentional Injuries Safety Belts, Alcohol, Home Hazards
Chronic Lung Disease Tobacco, Environmental Exposure

12. REAL Leading Causes of Death*
Tobacco ,000
Diet/Physical Activity 365,000
Alcohol ,000
Microbial Agents ,000
Toxic Agents ,000
Motor Vehicles ,000
Firearms ,000
Sexual Behavior ,000
Illicit Drug Use ,000
*2000 Estimates, unduplicated

13. What Influences Health Status the Most?
A: Genetics?
B: Environment?
C: Access to health services?
D: Health-related behaviors?

14. Influences on Health Status

15. Health Status: Influences and Expenditures

16. Strategies for Prevention: Levels
Reduce social determinants of illness
↓ unemployment
↑ standard of living
↑ education levels
Implement public health interventions
Purify water
Raise taxes on tobacco
Deliver clinical preventive services

17. Types of Clinical Prevention
Primary—
Prevent occurrence of disease or injury
Secondary—
Early detection of a disease process and intervention to keep it from progressing
Tertiary—
Efforts to minimize the effects of disease and disability

18. Clinical Preventive Services (CPS)
Counseling for risk reduction (smoking cessation)
Screening tests for the early detection of disease (Pap smears)
Immunizations for primary prevention (measles vaccination)
Chemoprophylaxis (estrogen therapy)

19. Do Clinical Preventive Services Work?

20. Smoking Cessation Counseling Works!
Over 40 different controlled trials
Combining counseling, literature, and nicotine replacement
Success found in helping 8-40% quit
Also shown to be cost effective
[We don’t know much about e-cigarette counseling]

21. Hypertension Screening Works!
17 percent reduction in mortality among treated hypertensives
Main cause of 50 percent reduction in stroke mortality in last two decades
Pharmacologic and non-pharmacologic measures effective

22. Breast Cancer Screening Works!
Worldwide studies show up to 35% reduction in breast cancer mortality
Especially well proven for women age 50 years old and above
Major barriers are lack of knowledge by patient and lack of MD recommendation

23. Cervical Cancer Screening Works!
Responsible for the dramatic reduction seen in cervical cancer mortality
Cooperative study showed 90% reduction in invasive cervical cancer with Pap smears
Special problem now is minority women and those in low SES groups

24. Adult Immunizations Work!
Influenza and pneumococcal vaccine are efficacious at preventing disease
Research has shown decreased costs in immunized groups, especially the elderly
Office and clinic reminder systems have been shown to increase immunization rates

25. How Good a Job are We Doing?
Preventive Practices of Primary Care Clinicians: a National Survey
and
Recent Data on Smoking Cessation Counseling Education in Med Schools

26. Purpose
Provide national baseline data for 17 Healthy People 2000 objectives
Measure preventive activities of primary care providers
Evaluate use of office resources for preventive care

27. Sampling AAFP AAP ACOG ACP NANP
Membership sampled 39, , , , ,500
Initial sample , , , , ,000
Response rate % % % % %
Final sample

28. Screening Tests
Proportion reporting routinely providing service to % of their patients who needed it:
Hematocrit: %
Cholesterol: %
Pap smear: %
Mammogram: %

29. Immunizations
Proportion reporting routinely providing service to % of patients needing it
DPT: %
Td booster: %
Pneumococcal: %
Influenza: %

30. Assessment/Counseling
Proportion reporting routinely providing service to % of patients:
Topic Inquiry Counseling
Physical activity 14-40% %
Diet/Nutrition % %
Tobacco use % %
Seat belt use % %

31. Caveats Group members only Complicated instrument
Variable response rates
Self-reported practices

32. Conclusions Even self-reported, many services poorly delivered
Many resources underutilized
Much room for improvement

33. How Good a Job are Medical Schools Doing at Teaching Preventive Care?

34. Smoking Cessation Education A National Survey
122/126 medical schools responded
69.2% of schools did not require clinical training in smoking cessation techniques
31% averaged less than 1 hour per year of smoking cessation counseling training
Conclusion: a majority of U.S. medical school graduates are not adequately trained in smoking cessation counseling

35. Barriers to Implementation of Preventive Services
Clinical uncertainty about which services to offer—ACA has helped
Financing constraints—ACA has helped
Organizational issues in the office—ACA has helped
Physician education, attitudes
Patient education, attitudes

36. Poll: Does Clinical Prevention Save Money?
A: Yes, lots
B: No, it costs more
C: It depends
D: Wrong question

37. Digression: Does Clinical Prevention Save Money?
A: Yes, lots
B: No, it costs more
C: It depends
D: Wrong question

38. Tools You Can Use
U.S. Preventive Services Task Force’s Guide to Clinical Preventive Services

39. U.S. Preventive Services Task Force Guide to Clinical Preventive Services
Evaluates the evidence of effectiveness of clinical preventive services
Makes age-, sex-, risk factor-specific recommendations

40. USPSTF Methodology Select target positions and preventive services
Systematically search literature
Evaluate quality of evidence
Formulate recommendations
Conduct external review

41. Digression: How do you decide what is an effective preventive service?

42. USPSTF Recommendations
Quality of the evidence
RCT>case control study>>expert opinion
Strength of the recommendation, based on
Effectiveness of the intervention
Burden of suffering
Characteristics of the intervention

43. ePSS: USPSTF on your phone

44. USPSTF Principal Findings
Interventions that address personal health practices are important
The clinician and patient should share decision making
Clinicians should be selective in ordering tests and providing clinical services
Clinicians must take every opportunity to deliver preventive services
For some health problems, community interventions may be more effective than clinical preventive services

45. Take-Home Clinical Messages
Preventive care is important--and it works
Health-related behaviors control many of the leading causes of death (smoking!)
You need to learn these skills to be a good doctor (smoking!)
Focus on preventive services for which there is evidence of effectiveness: good value for the $
Insist on learning this material in your training! (especially smoking cessation)

46. Take-Home Policy Messages
Key to prevention is system changes at all levels:
Clinical systems (e.g., EMRs, practice policies)
Insurance systems (e.g., coverage, deductibles, co-pays)
Governmental systems (e.g., mandates, legislation, research)

47. Contact Info
For US Preventive Services Task Force
For Doug Kamerow:

48. Digression: e-Cigarettes: Panacea or Disaster?

49. Poll: What’s the Story on e-Cigarettes?
A. They come in kid-friendly flavors B. They can help you stop smoking C. They can impede smoking cessation D. They’re better for you than cigarettes E. We don’t really know what’s in them F. All of the above

50. Poll: What’s the Story on e-Cigarettes?
A. They come in kid-friendly flavors B. They can help you stop smoking C. They can impede smoking cessation D. They’re better for you than cigarettes E. We don’t really know what’s in them F. All of the above

51. e-Cigarettes What are e-cigarettes? How are they sold and promoted?
How popular?
Regulated?
What are their effects for good or ill?
What should doctors do?