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The Role of the Health Care System in Primordial Prevention
Preventive Medicine 29, S59–S65 (1999) Article ID pmed.1999.0461, available online at http://www.idealibrary.com on
The Role of the Health Care System in Primordial Prevention Robert F. DeBusk, M.D.1 School of Medicine, Stanford University, Palo Alto, California 94304
The health care system has the resources to assume an important role in primordial prevention. The extent to which it does so will be determined largely by the financial and economic forces that are transforming the health care system. There is reason to be optimistic about the effectiveness of a partnership between community-based organizations and medical centers in addressing the challenges of primordial prevention in the 21st century. q 1999 American Health Foundation and Academic Press Key Words: health care changes; economics; community prevention.
INTRODUCTION
Primordial prevention, which deals with the mitigation of risky behaviors and risk factors, has its scientific roots in epidemiology and its locus of action in the community. Most of the improvement in the health status of Americans during the first half of the 20th century and much of the improvement in the second half is attributable to community-based public health initiatives. The conquest of infectious diseases during the first half of the 20th century and the reduction of degenerative vascular diseases in the second half represent major achievements for this approach. Henry Blackburn of the University of Minnesota, John Farquhar of Stanford University, and Richard Carleton of Brown University of Rhode Island were pioneers in this field. However, other scourges that threaten the public health, especially illicit drugs, unsafe sex, and violence, have assumed larger roles during the past quarter century. These scourages have preempted the resources that proved successful in preventing the effects of degenerative vascular diseases. Consequently, the indigent, multiethnic communities most in need of public health approaches to primordial prevention, including smoking cessation, screening and treatment for hypertension, and changes in diet now lack the resources to 1
Fax: (650) 723–6798.
address either the earlier or the later scourges. Moreover, cutbacks in federal and state funding threaten to erode the base of community health still further. The health care system, epitomized by community and university hospitals, has generally failed to address the deteriorating health status of their surrounding communities, whether affluent or indigent. This reluctance to beomce involved in community health reflects the long-standing schism between preventive and curative medicine in America described so brilliantly by Paul Starr in his book, The Social Transformation of American Medicine [1]. This symposium has been convened to address the systemic problems that have perpetuated the disconnection between curative and preventive medicine and to honor Henry Blackburn, who has devoted his long and distinguished career to understanding the barriers to primordial prevention and devising effective strategies to overcome them. Here I argue that the health care system has much to contribute to primordial prevention. The current dislocations in the American health care industry that have engendered so much concern among academicians and practitioners actually afford many new opportunities to address primordial health in new ways. Indeed, it can be argued that the imperative for primordial prevention has never been stronger. The acceleration of health-related technology, the aging of the population, and the continuing proportion of gross domestic product devoted to health, without a corresponding improvement in important health care indices, all indicate that the current trajectory of the health care system is unsustainable. It is economically and politically imperative that lowcost primordial prevention be substituted for high-cost treatments. What follows is a prescription for mobilizing the requisite knowledge, capital, and management expertise that exist within the health care system to foster primordial prevention. An essential element in this strategy is to integrate community-based approaches to low-risk patients, which has been the traditional domain of the M.P.H.-trained public health specialist, with
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0091-7435/99 $30.00 Copyright q 1999 by American Health Foundation and Academic Press All rights of reproduction in any form reserved.
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clinic-based approaches to high-risk patients, which has been the traditional domain of the M.D.-trained specialist. The resulting hybrid can provide community-oriented care for an entire community (Fig. 1). OBSTACLES TO PRIMORDIAL PREVENTION IN THE EXISTING HEALTH CARE SYSTEM
Organizational Primordial prevention cannot simply be engrafted onto the existing health care system, which is generally configured to deal with office-based or hospital-based acute care encounters. The effectiveness of primordial prevention relies on continuity of care over an extended period. Physicians are often too distracted by urgent situations to attend to preventive care. This results in discontinuity for primordial prevention. Financial Payors and health care providers are generally reluctant to pay for primordial prevention for the following reasons: • The financial investment of payors and providers in prevention is predicated on the avoidance or delay of costly diseases. By definition, efforts in primordial prevention such as prevention and treatment of hyperlipidemia or hypertension must extend over a period of years. However, patients move freely into and out of health plans over time. This means that payors and providers often cannot recoup their investment in patients who move to other health plans, in many cases after having received preventive care for many years. While a single-payor system would largely overcome this problem, such a program is unlikely to be implemented in the near future. • Preventive services provided through the health care system, especially medications to treat risk factors such as hypertension and hyperlipidemia, incur large long-term costs. The cost of each quality-adjusted life
year saved in individuals free of disease at baseline is often expressed in multiples of $100,000. This cost is often viewed by benefits managers as excessive. • Even if the costs of preventing diseases are high, they can be deferred. In contrast, expenditures for acute medical conditions generally cannot be deferred. • Moreover, even in ‘‘mature’’ medical markets served by a small number of health plans serving a large proportion of patients, the patients are often distributed over a large geographic area, which is a major barrier to the efficient delivery of preventive services. Physician-Related • Physicians generally favor treatment over prevention because the results of the former are manifest sooner and are perceived as professionally and economically more rewarding. Reimbursement for preventive services is generally meager compared to treatment services. • Physicians are generally pessimistic about their efficacy in helping patients to change risky behaviors and risk factors, and their pessimism is often borne out, as in smoking cessation, where one-year physicianassisted cessation rates are only about 5% [2]. • Physicians are rarely gratified by small changes in patients’ risk factors such as a 10% reduction in plasma cholesterol, despite the fact that, on a population basis, such a reduction may result in a 20% lower cardiovascular risk or a saving of as many as 100,000 lives annually. • Physicians are taught to think and act in terms of benefits to individual patients rather than benefits to the population as a whole. This has cultural and ethical roots in the Hippocratic oath recently updated as the ‘‘Patient–Physician Covenant.’’ It also has roots in the training of physicians, which generally slights the discipline of epidemiology. • The responsibility for prevention is often diffused among multiple physicians. The resulting ambiguity often means that primary care physicians, who do not have the time to pursue prevention, defer to specialists, who may have the time and expertise to provide preventive services, but rarely have the financial or professional incentives to do so. HOW THE HEALTH CARE SYSTEM CAN PLAY AN EFFECTIVE ROLE IN PRIMORDIAL PREVENTION
FIG. 1. An emerging management paradigm.
Large provider groups, especially under managed care, have an incentive to substitute primordial prevention, at low cost, for high-tech treatments, at high cost. These large provider groups have the medical expertise, capital, and organizational talent to provide new options for primordial prevention that are more cost-effective and readily available than existing alternatives in the health care system or in community-based programs.
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HEALTH CARE SYSTEM IN PRIMORDIAL PREVENTION
Community-based clinics are under increasing financial duress and many have disappeared altogether. Specifically, the medical center and its affiliated clinics are often better suited than community-based approaches to coordinate certain aspects of primordial care in large populations including certain behaviors such as smoking and risk factors such as hypertension and hyperlipidemia. For example, worksite programs generally serve only the 15% of the workforce that is employed in businesses having 100 or more workers on-site. The vast majority of businesses employ too few workers to support traditional worksite programs. Other issues in primordial prevention, including unsafe sexual practices, access to tobacco, illicit drugs, and violence are better addressed through communityinitiated action. But it is essential that medical centers and community organizations cooperate to address many overlapping issues. Finally, the medical center and its affiliated clinics are able to provide full-service care when primordial prevention fails and patients require secondary prevention for the management of vascular diseases. HOW BARRIERS TO THE DELIVERY OF PREVENTIVE SERVICES BY THE HEALTH CARE SYSTEM CAN BE OVERCOME: THE EXAMPLE OF SMOKING CESSATION
In collaboration with Kaiser Permanente hospitals and the Stanford Medical Center, the Stanford Cardiac Rehabilitation Program has developed and deployed hospital-based smoking cessation programs that serve the entire community. The rationale for initiating hospital-based smoking cessation is that most California hospitals have smoking bans, which render smokers abstinent, at least for the few days in which they are hospitalized. Our prior experience with post-MI patients indicated that a high rate of cessation at 1 year could be achieved if such patients were counseled on avoiding relapse during hospitalization and received continuing smoking instruction by phone in the weeks following hospital discharge. The first of these studies documented a 73% cessation rate in patients receiving the relapse prevention intervention versus a 45% rate in usual care [3]. A subsequent study, in which relapse prevention was incorporated into a multicomponent risk factor management program for post-MI patients that included diet–drug management of hyperlipidemia and exercise training, documented a 60% 1-year cessation rate among patients receiving the relapse prevention intervention versus a 50% rate among patients receiving usual care [4]. The content of this program is outlined in Table 1. More recently, we have applied the same management principles to a general population of smokers hospitalized in Kaiser Permanente Medical Centers. The
TABLE 1 Smoking Cessation for Hospitalized Patients Hospital-based nurse counseling, postdischarge phone follow-up Videotape for in-hospital viewing Workbook for individualized home use Relaxation auditotape for home use Nurse-managed nicotine replacement therapy
objectives of this study were (1) to compare the efficiacy of single versus multiple postdischarge telephone contacts among patients receiving an in-hopsital smoking counseling intervention and (2) to identify patient subsets for whom the intervention was particularly efficacious. The study design is shown in Table 2. The 1year confirmed cessation rates for intensive follow-up, minimal follow-up, and usual care groups were 27, 21, and 20%, respectively [5]. Consistent with other studies, [6,7] the cessation rates were higher among patients with cardiovascular disease than among patients admitted with an internal medicine (as opposed to surgical) diagnosis (Fig. 2). We used signal detection analysis to evaluate the baseline variables associated with success (the 60% of the population with a cessation rate greater than 27%) or failure (the 40% of the population with cessation rates below 27%). The following hierarchy of variables was noted among successful patients; the most important predictor variables were confidence of 100% to remain a nonsmoker, lack of depression, a low rate of addiction by the Fagerstrom Tolerance Questionnaire, and no alcohol consumption. Among patients who failed (cessation rate less than 27%), the most important predictor variables were age less than 45 years and alcohol consumption. These patients also experienced depression and a high level of addiction to nicotine. These data are important in identifying patients with special needs, particularly those with combined alcohol– nicotine addiction.
TABLE 2 Smoking Cessation Trial Design In-hospital Usual care (n 5 962) Minimal Rx (n 5 458) Intensive Rx (n 5 548)
M.D., R.N. advice AHA pamphlet M.D., R.N. advice 1 R.N. counseling 1 A-V materials M.D., R.N. Advice 1 R.N. counseling 1 Instruct. Prog.
Postdischarge
Single phone follow-up at, 48 h Phone follow-up at 48 h 1 7, 21, 90 days
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FIG. 2. 12-month confirmed cessation rates—CVD/other internal medicine patients.
The cessation rates observed in this study are substantially higher than those observed in general ambuulatory care provided by primary care physicians. While physician advice to quit is an important component of hospital-based smoking cessation efforts, it is not necessary for the physician to implement the detailed hospital counseling and phone follow-up. As in our previous studies, nurses were effective in these roles. The importance of nurses’ participation resides not only in their success but in the fact that they represent a substantial additional resource for community-based primordial prevention. There are nearly 1 million licensed nurses in America and many are seeking new roles in a restructured health care system. In extending this work to the Stanford Medical Center (SMC) we have learned important lessons about the hospital-wide deployment of smoking cessation programs. The features of this program are shown in Table 3. Among 13,000 patients screened in 1993–1996, 4,000 (31%) were smokers, of whom 2,000 were eligible and available. Of these 1,000 were enrolled and at 1 year 350 or 35% reported abstinence from smoking. This
TABLE 3 Hospital-Based Service Program for Smoking Cessation (SMC) Blanket approval for nurse manager to contact patients Identification of patients by admitting office, nursing history, M.D. or nurse referral Exclusions: language barrier, medical complications, alcoholism, M.D. refusal (1–2%), patient refusal (33%) Nurse-initiated hospital-based counseling, including 4 followup phone contacts Nurse-mediated nicotine replacement therapy Program support provided by SMC
proportion is similar to that noted in our randomization trial, in which abstinence was chemically confirmed. The fact that only 1,000 of 2,000 eligible patients were available to undergo in-hospital counseling speaks to the need to provide phone-based counseling to patients whose hospital stay is brief. As shown in Fig. 3, a hospital-based management system enables patients to be treated in many venues, including single- and multispecialty clinics. Nonphysicians and telecommunications will play an increasingly important role in the delivery of services to promote primordial prevention. These smoking cessation programs have important implications not only for the organization of primary prevention services but for the financing of such programs. The nurse case managers offered services to patients irrespective of their insurance coverage or the practice arrangements of their attending physicians. The costs of the smoking cessation programm were covered by the Stanford Medical Center as part of its community-based mission. Despite the fact that smoking cessation programs are among the more cost effective of all primary prevention initiatives, their financing is problematic. Schauffler and Rodriguez have noted ‘‘To the extent that purchasers continue to try to define ‘value’ as health improvement, they eventually will force health plans to look outside the confines of the clinical encounter and beyond the actions of physicians to identify others with whom they can work to influence the health behavior of individuals and the health of our communities’’ [8]. To facilitate coverage for preventive measures, including smoking cessation, the Pacific Business Group on Health has adopted a three-phase program to provide incentives for insurers. This includes adoption of guidelines for prevention, rewarding health plans that implement the guidelines, and providing economic inventives
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FIG. 3. Case management for primordial prevention.
for health care providers to offer preventive services [9]. Although the program has made steady progress, numerous problems in each phase of implementation have encumbered the group’s efforts to provide an economic incentive for health plans to offer preventive services. Still, this experience is encouraging. Weinstein has noted that preventive effects do not generally save money nor should they be expected to do so. ‘‘Prevention is not the answer to the nation’s health care cost problem. With a few notable exceptions, a dollar spent on prevention does not yield a dollar saved on diagnosis or treatment. This fact has been demonstrated in numerous economic evaluations of prevention programs, covering blood pressure treatment, cancer screening, exercise counseling, and even some immunizations. The goal of prevention is to reduce mortality and improve health status, not to make money. Why, then should we demand of disease prevention more than we demand of disease treatment? Both compete for shares of the health care budget, and they should do so on equal terms. The appropriate question is not whether prevention can make money for the payers for health care, but whether it promotes health at a reasonable price. The appropriate standard of comparison is not a positive economic ‘profit’, but a cost-effective ratio comparable with or superior to those of other health care practices’’ [9]. In our studies, the cost of intervention on each patient who quit smoking was $171 for patients with cardiovascular disease and $215 for patients with other internal medicine diagnoses. The costs per extra quitter for these two groups (the net cost of intervention, considering the spontaneous quit rate) were $580 and $483, respectively [10]. But cost effectiveness itself is no guarantee of dissemination of smoking cessation programs.
Too little attention has been devoted to the process of widespread dissemination of pilot projects into treatment practice. The necessary elements for dissemination of the case management model, for example, include a training course for nonphysicians, educational materials for patients, and software to facilitate the nurses’ task of evaluating patients and tracking their progress with timely phone prompts. We have incorporated these components into a standardized program that can be widely disseminated. One of the shortcomings of preventive efforts has been the lack of standardized behaviorally oriented programs that lend themselves to widespread dissemination. This process requires capitalization, not only for creation of the programs but also for marketing, systems support, and the other commercial functions common to dissemination of drugs and devices into treatment practice. Although systems of preventive care are in a relatively early phase of development and dissemination, it seems clear that increasing resources will be devoted to them as medicine moves from being a ‘‘trillion-dollar cottage industry’’ to a more highly standardized service industry. ORGANIZATIONAL CHANGES THAT FOSTER PRIMORDIAL PREVENTION
Many new relationships are emerging among physicians and ‘‘third parties,’’ including managed-care arrangements (closed-panel, independent practice associations, point-of-service plans) and hospitals and clinics and insurers that provide ‘‘preventive’’ as well as ‘‘curative’’ services. The aspect of managed care that has most dramatically transformed ‘‘curative’’ health care delivery is capitation, in which all care is provided for a
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flat monthly fee. However, under most capitated plans, funds available for primordial prevention are currently quite small in relation to funds available for curative treatments. The health care system is being restructured along the lines of other service ‘‘industries’’ and being subjected to the same market forces that influence these industries. (1) It is being reorganized to use the optimal provider in the appropriate setting and at the proper time. For example, the proportion of lower-paid generalist ‘‘gate keepers’’ is being increased and the proportion of higher-paid specialists is being decreased. (2) Many services previously provided in hospitals are now offered in outpatient facilities. (3) Many tasks performed exclusively by physicians are now performed by nonphysicians, including nurse practitioners, special practice nurses, and physicians’ assistants. Major attempts are being made to introduce practice guidelines and ‘‘best practices’’ into clinical care. Many of these guidelines concern risky behaviors such as smoking and risk factors such as hypertension, which are being incorporated into a continuum of care that connects primordial prevention with secondary and tertiary care. Health care providers are attempting to assign tasks to members of health care teams that include physicians and nonphysicians who use a variety of technologies to foster primordial prevention, including phones, mail, electronic mail, etc., For example nonphysicians, especially nurses, are effective in directing preventive services for hypertension, hyperlipidemia, and smoking. Displacing the office or clinic visit as the exclusive transactional basis of health care delivery enables new staffing and contact patterns by phone and mail that have major implications for primordial prevention as well as for health care generally. Computerized medical databases can support the efficient delivery of primordial prevention, allowing for efficient data capture and display, report generation, prompting, and decision support over an extended period. This ‘‘infrastructure’’ does not presently exist for primordial prevention as it is provided by individual physicians. PERSONNEL-RELATED CHANGES THAT FOSTER PRIMORDIAL PREVENTION
An integrated health care system in which many or most contacts for primordial prevention were with specially trained nonphysicians, generally by means other than office visits, such as phone calls, would provide greater convenience in achieving the goals of primordial prevention. Specially trained nonphysicians, most of whom have nursing degrees, have mastered a set of behaviorally oriented skills that renders them at least as effective as physicians as change agents.
Primary prevention, as provided by vertically integrated medical centers, can be coordinated efficiently with other aspects of care provided by generalist and specialist physicians. This coordination is facilitated by the computer, phone, mail, and other communications linkages noted above. The hospital-based smoking cessation program cited above is an example of communityoriented primary prevention.
FINANCIAL CHANGES THAT FOSTER PRIMORDIAL PREVENTION
Prevention may increasingly be mandated by employer-driven quality assurance processes such as HEDIS 2.0 (Health Plan Employer and Data Information Set) developed by the National Committee for Quality Assurance [11]. Health plans that do not offer primary prevention may find themselves at a competitive disadvantage in the medical marketplace. Even without the impetus of employer mandates, health care providers are increasingly turning to prevention to attract a broader patient base. More cost-effective methods of primary prevention may stimulate renewed interest in prevention among health care providers. For example, smoking cessation counseling by nonphysicians provided during hospitalization and followed by postdischarge phone contacts has demonstrated 1-year quit rates of nearly 30 to 40% among a general population of patients [5]. This approach may be more cost effective than prevention offered during routine outpatient visits.
REFERENCES 1. Starr P. The social transformation of American medicine. New York: Basic Books, 1982. 2. Kottke TE, Battista RN, DeFriese GH, Brekke ML. Attributes of successful smoking cessation interventions in medical practice: a meta-analysis of 39 controlled trials. JAMA 1988;259:2883–9. 3. Taylor CB, Houston Miller N, Killen JD, DeBusk RF. Smoking cessation after acute myocardial infarction: effects of a nursemanaged intervention. Ann Intern Med 1990;113:118–23. 4. DeBusk RF, Miller NH, Superko HR, Dennis CA, Thomas RJ. Lew HT, et al. A case management system for coronary risk factor modification following acute myocardial infarction. Ann Intern Med 1994;120:721–9. 5. Taylor CB, Houston Miller N, Herman S, Smith PM, Dobel D, Fisher L, et al. A nurse-managed smoking cessation program for hospitalized smokers. Am J Public Health 1997;86:1557–60. 6. Orleans CT, Christeller JL, Gritz ER. Helping hospitalized smokers quit: new directions for treatment and research. J Consult Clin. Psychol 1993;61:778–9. 7. Orleans CT, Ockene JK. Routine hospital-based quit-smoking
HEALTH CARE SYSTEM IN PRIMORDIAL PREVENTION treatment for the post-myocardial infarction patient: an idea whose time has come. J Am Coll Cardiol 1993;22:1703–5. 8. Schauffler HH, Rodriguez T. Exercising purchasing power for preventive care. Health Affairs 1995;15:73–85. 9. Weinstein MC. Economics of prevention. J Gen Intern Med 1990;5 Suppl:S89–S92.
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10. Smith PM, Houston Miller N, Taylor CB, DeBusk RF. Cost effectiveness of a smoking cessation program in hospitalized patients [Manuscript in preparation]. 11. National Committee for Quality Assurance. Health Plan Employer Data and Information Set (HEDIS), Version 2.0. Washington: NCQA, 1993 Oct.
The Role of the Health Care System in Primordial Prevention Robert F. DeBusk, M.D.1 School of Medicine, Stanford University, Palo Alto, California 94304
The health care system has the resources to assume an important role in primordial prevention. The extent to which it does so will be determined largely by the financial and economic forces that are transforming the health care system. There is reason to be optimistic about the effectiveness of a partnership between community-based organizations and medical centers in addressing the challenges of primordial prevention in the 21st century. q 1999 American Health Foundation and Academic Press Key Words: health care changes; economics; community prevention.
INTRODUCTION
Primordial prevention, which deals with the mitigation of risky behaviors and risk factors, has its scientific roots in epidemiology and its locus of action in the community. Most of the improvement in the health status of Americans during the first half of the 20th century and much of the improvement in the second half is attributable to community-based public health initiatives. The conquest of infectious diseases during the first half of the 20th century and the reduction of degenerative vascular diseases in the second half represent major achievements for this approach. Henry Blackburn of the University of Minnesota, John Farquhar of Stanford University, and Richard Carleton of Brown University of Rhode Island were pioneers in this field. However, other scourges that threaten the public health, especially illicit drugs, unsafe sex, and violence, have assumed larger roles during the past quarter century. These scourages have preempted the resources that proved successful in preventing the effects of degenerative vascular diseases. Consequently, the indigent, multiethnic communities most in need of public health approaches to primordial prevention, including smoking cessation, screening and treatment for hypertension, and changes in diet now lack the resources to 1
Fax: (650) 723–6798.
address either the earlier or the later scourges. Moreover, cutbacks in federal and state funding threaten to erode the base of community health still further. The health care system, epitomized by community and university hospitals, has generally failed to address the deteriorating health status of their surrounding communities, whether affluent or indigent. This reluctance to beomce involved in community health reflects the long-standing schism between preventive and curative medicine in America described so brilliantly by Paul Starr in his book, The Social Transformation of American Medicine [1]. This symposium has been convened to address the systemic problems that have perpetuated the disconnection between curative and preventive medicine and to honor Henry Blackburn, who has devoted his long and distinguished career to understanding the barriers to primordial prevention and devising effective strategies to overcome them. Here I argue that the health care system has much to contribute to primordial prevention. The current dislocations in the American health care industry that have engendered so much concern among academicians and practitioners actually afford many new opportunities to address primordial health in new ways. Indeed, it can be argued that the imperative for primordial prevention has never been stronger. The acceleration of health-related technology, the aging of the population, and the continuing proportion of gross domestic product devoted to health, without a corresponding improvement in important health care indices, all indicate that the current trajectory of the health care system is unsustainable. It is economically and politically imperative that lowcost primordial prevention be substituted for high-cost treatments. What follows is a prescription for mobilizing the requisite knowledge, capital, and management expertise that exist within the health care system to foster primordial prevention. An essential element in this strategy is to integrate community-based approaches to low-risk patients, which has been the traditional domain of the M.P.H.-trained public health specialist, with
S59
0091-7435/99 $30.00 Copyright q 1999 by American Health Foundation and Academic Press All rights of reproduction in any form reserved.
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ROBERT F. DEBUSK
clinic-based approaches to high-risk patients, which has been the traditional domain of the M.D.-trained specialist. The resulting hybrid can provide community-oriented care for an entire community (Fig. 1). OBSTACLES TO PRIMORDIAL PREVENTION IN THE EXISTING HEALTH CARE SYSTEM
Organizational Primordial prevention cannot simply be engrafted onto the existing health care system, which is generally configured to deal with office-based or hospital-based acute care encounters. The effectiveness of primordial prevention relies on continuity of care over an extended period. Physicians are often too distracted by urgent situations to attend to preventive care. This results in discontinuity for primordial prevention. Financial Payors and health care providers are generally reluctant to pay for primordial prevention for the following reasons: • The financial investment of payors and providers in prevention is predicated on the avoidance or delay of costly diseases. By definition, efforts in primordial prevention such as prevention and treatment of hyperlipidemia or hypertension must extend over a period of years. However, patients move freely into and out of health plans over time. This means that payors and providers often cannot recoup their investment in patients who move to other health plans, in many cases after having received preventive care for many years. While a single-payor system would largely overcome this problem, such a program is unlikely to be implemented in the near future. • Preventive services provided through the health care system, especially medications to treat risk factors such as hypertension and hyperlipidemia, incur large long-term costs. The cost of each quality-adjusted life
year saved in individuals free of disease at baseline is often expressed in multiples of $100,000. This cost is often viewed by benefits managers as excessive. • Even if the costs of preventing diseases are high, they can be deferred. In contrast, expenditures for acute medical conditions generally cannot be deferred. • Moreover, even in ‘‘mature’’ medical markets served by a small number of health plans serving a large proportion of patients, the patients are often distributed over a large geographic area, which is a major barrier to the efficient delivery of preventive services. Physician-Related • Physicians generally favor treatment over prevention because the results of the former are manifest sooner and are perceived as professionally and economically more rewarding. Reimbursement for preventive services is generally meager compared to treatment services. • Physicians are generally pessimistic about their efficacy in helping patients to change risky behaviors and risk factors, and their pessimism is often borne out, as in smoking cessation, where one-year physicianassisted cessation rates are only about 5% [2]. • Physicians are rarely gratified by small changes in patients’ risk factors such as a 10% reduction in plasma cholesterol, despite the fact that, on a population basis, such a reduction may result in a 20% lower cardiovascular risk or a saving of as many as 100,000 lives annually. • Physicians are taught to think and act in terms of benefits to individual patients rather than benefits to the population as a whole. This has cultural and ethical roots in the Hippocratic oath recently updated as the ‘‘Patient–Physician Covenant.’’ It also has roots in the training of physicians, which generally slights the discipline of epidemiology. • The responsibility for prevention is often diffused among multiple physicians. The resulting ambiguity often means that primary care physicians, who do not have the time to pursue prevention, defer to specialists, who may have the time and expertise to provide preventive services, but rarely have the financial or professional incentives to do so. HOW THE HEALTH CARE SYSTEM CAN PLAY AN EFFECTIVE ROLE IN PRIMORDIAL PREVENTION
FIG. 1. An emerging management paradigm.
Large provider groups, especially under managed care, have an incentive to substitute primordial prevention, at low cost, for high-tech treatments, at high cost. These large provider groups have the medical expertise, capital, and organizational talent to provide new options for primordial prevention that are more cost-effective and readily available than existing alternatives in the health care system or in community-based programs.
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Community-based clinics are under increasing financial duress and many have disappeared altogether. Specifically, the medical center and its affiliated clinics are often better suited than community-based approaches to coordinate certain aspects of primordial care in large populations including certain behaviors such as smoking and risk factors such as hypertension and hyperlipidemia. For example, worksite programs generally serve only the 15% of the workforce that is employed in businesses having 100 or more workers on-site. The vast majority of businesses employ too few workers to support traditional worksite programs. Other issues in primordial prevention, including unsafe sexual practices, access to tobacco, illicit drugs, and violence are better addressed through communityinitiated action. But it is essential that medical centers and community organizations cooperate to address many overlapping issues. Finally, the medical center and its affiliated clinics are able to provide full-service care when primordial prevention fails and patients require secondary prevention for the management of vascular diseases. HOW BARRIERS TO THE DELIVERY OF PREVENTIVE SERVICES BY THE HEALTH CARE SYSTEM CAN BE OVERCOME: THE EXAMPLE OF SMOKING CESSATION
In collaboration with Kaiser Permanente hospitals and the Stanford Medical Center, the Stanford Cardiac Rehabilitation Program has developed and deployed hospital-based smoking cessation programs that serve the entire community. The rationale for initiating hospital-based smoking cessation is that most California hospitals have smoking bans, which render smokers abstinent, at least for the few days in which they are hospitalized. Our prior experience with post-MI patients indicated that a high rate of cessation at 1 year could be achieved if such patients were counseled on avoiding relapse during hospitalization and received continuing smoking instruction by phone in the weeks following hospital discharge. The first of these studies documented a 73% cessation rate in patients receiving the relapse prevention intervention versus a 45% rate in usual care [3]. A subsequent study, in which relapse prevention was incorporated into a multicomponent risk factor management program for post-MI patients that included diet–drug management of hyperlipidemia and exercise training, documented a 60% 1-year cessation rate among patients receiving the relapse prevention intervention versus a 50% rate among patients receiving usual care [4]. The content of this program is outlined in Table 1. More recently, we have applied the same management principles to a general population of smokers hospitalized in Kaiser Permanente Medical Centers. The
TABLE 1 Smoking Cessation for Hospitalized Patients Hospital-based nurse counseling, postdischarge phone follow-up Videotape for in-hospital viewing Workbook for individualized home use Relaxation auditotape for home use Nurse-managed nicotine replacement therapy
objectives of this study were (1) to compare the efficiacy of single versus multiple postdischarge telephone contacts among patients receiving an in-hopsital smoking counseling intervention and (2) to identify patient subsets for whom the intervention was particularly efficacious. The study design is shown in Table 2. The 1year confirmed cessation rates for intensive follow-up, minimal follow-up, and usual care groups were 27, 21, and 20%, respectively [5]. Consistent with other studies, [6,7] the cessation rates were higher among patients with cardiovascular disease than among patients admitted with an internal medicine (as opposed to surgical) diagnosis (Fig. 2). We used signal detection analysis to evaluate the baseline variables associated with success (the 60% of the population with a cessation rate greater than 27%) or failure (the 40% of the population with cessation rates below 27%). The following hierarchy of variables was noted among successful patients; the most important predictor variables were confidence of 100% to remain a nonsmoker, lack of depression, a low rate of addiction by the Fagerstrom Tolerance Questionnaire, and no alcohol consumption. Among patients who failed (cessation rate less than 27%), the most important predictor variables were age less than 45 years and alcohol consumption. These patients also experienced depression and a high level of addiction to nicotine. These data are important in identifying patients with special needs, particularly those with combined alcohol– nicotine addiction.
TABLE 2 Smoking Cessation Trial Design In-hospital Usual care (n 5 962) Minimal Rx (n 5 458) Intensive Rx (n 5 548)
M.D., R.N. advice AHA pamphlet M.D., R.N. advice 1 R.N. counseling 1 A-V materials M.D., R.N. Advice 1 R.N. counseling 1 Instruct. Prog.
Postdischarge
Single phone follow-up at, 48 h Phone follow-up at 48 h 1 7, 21, 90 days
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FIG. 2. 12-month confirmed cessation rates—CVD/other internal medicine patients.
The cessation rates observed in this study are substantially higher than those observed in general ambuulatory care provided by primary care physicians. While physician advice to quit is an important component of hospital-based smoking cessation efforts, it is not necessary for the physician to implement the detailed hospital counseling and phone follow-up. As in our previous studies, nurses were effective in these roles. The importance of nurses’ participation resides not only in their success but in the fact that they represent a substantial additional resource for community-based primordial prevention. There are nearly 1 million licensed nurses in America and many are seeking new roles in a restructured health care system. In extending this work to the Stanford Medical Center (SMC) we have learned important lessons about the hospital-wide deployment of smoking cessation programs. The features of this program are shown in Table 3. Among 13,000 patients screened in 1993–1996, 4,000 (31%) were smokers, of whom 2,000 were eligible and available. Of these 1,000 were enrolled and at 1 year 350 or 35% reported abstinence from smoking. This
TABLE 3 Hospital-Based Service Program for Smoking Cessation (SMC) Blanket approval for nurse manager to contact patients Identification of patients by admitting office, nursing history, M.D. or nurse referral Exclusions: language barrier, medical complications, alcoholism, M.D. refusal (1–2%), patient refusal (33%) Nurse-initiated hospital-based counseling, including 4 followup phone contacts Nurse-mediated nicotine replacement therapy Program support provided by SMC
proportion is similar to that noted in our randomization trial, in which abstinence was chemically confirmed. The fact that only 1,000 of 2,000 eligible patients were available to undergo in-hospital counseling speaks to the need to provide phone-based counseling to patients whose hospital stay is brief. As shown in Fig. 3, a hospital-based management system enables patients to be treated in many venues, including single- and multispecialty clinics. Nonphysicians and telecommunications will play an increasingly important role in the delivery of services to promote primordial prevention. These smoking cessation programs have important implications not only for the organization of primary prevention services but for the financing of such programs. The nurse case managers offered services to patients irrespective of their insurance coverage or the practice arrangements of their attending physicians. The costs of the smoking cessation programm were covered by the Stanford Medical Center as part of its community-based mission. Despite the fact that smoking cessation programs are among the more cost effective of all primary prevention initiatives, their financing is problematic. Schauffler and Rodriguez have noted ‘‘To the extent that purchasers continue to try to define ‘value’ as health improvement, they eventually will force health plans to look outside the confines of the clinical encounter and beyond the actions of physicians to identify others with whom they can work to influence the health behavior of individuals and the health of our communities’’ [8]. To facilitate coverage for preventive measures, including smoking cessation, the Pacific Business Group on Health has adopted a three-phase program to provide incentives for insurers. This includes adoption of guidelines for prevention, rewarding health plans that implement the guidelines, and providing economic inventives
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FIG. 3. Case management for primordial prevention.
for health care providers to offer preventive services [9]. Although the program has made steady progress, numerous problems in each phase of implementation have encumbered the group’s efforts to provide an economic incentive for health plans to offer preventive services. Still, this experience is encouraging. Weinstein has noted that preventive effects do not generally save money nor should they be expected to do so. ‘‘Prevention is not the answer to the nation’s health care cost problem. With a few notable exceptions, a dollar spent on prevention does not yield a dollar saved on diagnosis or treatment. This fact has been demonstrated in numerous economic evaluations of prevention programs, covering blood pressure treatment, cancer screening, exercise counseling, and even some immunizations. The goal of prevention is to reduce mortality and improve health status, not to make money. Why, then should we demand of disease prevention more than we demand of disease treatment? Both compete for shares of the health care budget, and they should do so on equal terms. The appropriate question is not whether prevention can make money for the payers for health care, but whether it promotes health at a reasonable price. The appropriate standard of comparison is not a positive economic ‘profit’, but a cost-effective ratio comparable with or superior to those of other health care practices’’ [9]. In our studies, the cost of intervention on each patient who quit smoking was $171 for patients with cardiovascular disease and $215 for patients with other internal medicine diagnoses. The costs per extra quitter for these two groups (the net cost of intervention, considering the spontaneous quit rate) were $580 and $483, respectively [10]. But cost effectiveness itself is no guarantee of dissemination of smoking cessation programs.
Too little attention has been devoted to the process of widespread dissemination of pilot projects into treatment practice. The necessary elements for dissemination of the case management model, for example, include a training course for nonphysicians, educational materials for patients, and software to facilitate the nurses’ task of evaluating patients and tracking their progress with timely phone prompts. We have incorporated these components into a standardized program that can be widely disseminated. One of the shortcomings of preventive efforts has been the lack of standardized behaviorally oriented programs that lend themselves to widespread dissemination. This process requires capitalization, not only for creation of the programs but also for marketing, systems support, and the other commercial functions common to dissemination of drugs and devices into treatment practice. Although systems of preventive care are in a relatively early phase of development and dissemination, it seems clear that increasing resources will be devoted to them as medicine moves from being a ‘‘trillion-dollar cottage industry’’ to a more highly standardized service industry. ORGANIZATIONAL CHANGES THAT FOSTER PRIMORDIAL PREVENTION
Many new relationships are emerging among physicians and ‘‘third parties,’’ including managed-care arrangements (closed-panel, independent practice associations, point-of-service plans) and hospitals and clinics and insurers that provide ‘‘preventive’’ as well as ‘‘curative’’ services. The aspect of managed care that has most dramatically transformed ‘‘curative’’ health care delivery is capitation, in which all care is provided for a
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flat monthly fee. However, under most capitated plans, funds available for primordial prevention are currently quite small in relation to funds available for curative treatments. The health care system is being restructured along the lines of other service ‘‘industries’’ and being subjected to the same market forces that influence these industries. (1) It is being reorganized to use the optimal provider in the appropriate setting and at the proper time. For example, the proportion of lower-paid generalist ‘‘gate keepers’’ is being increased and the proportion of higher-paid specialists is being decreased. (2) Many services previously provided in hospitals are now offered in outpatient facilities. (3) Many tasks performed exclusively by physicians are now performed by nonphysicians, including nurse practitioners, special practice nurses, and physicians’ assistants. Major attempts are being made to introduce practice guidelines and ‘‘best practices’’ into clinical care. Many of these guidelines concern risky behaviors such as smoking and risk factors such as hypertension, which are being incorporated into a continuum of care that connects primordial prevention with secondary and tertiary care. Health care providers are attempting to assign tasks to members of health care teams that include physicians and nonphysicians who use a variety of technologies to foster primordial prevention, including phones, mail, electronic mail, etc., For example nonphysicians, especially nurses, are effective in directing preventive services for hypertension, hyperlipidemia, and smoking. Displacing the office or clinic visit as the exclusive transactional basis of health care delivery enables new staffing and contact patterns by phone and mail that have major implications for primordial prevention as well as for health care generally. Computerized medical databases can support the efficient delivery of primordial prevention, allowing for efficient data capture and display, report generation, prompting, and decision support over an extended period. This ‘‘infrastructure’’ does not presently exist for primordial prevention as it is provided by individual physicians. PERSONNEL-RELATED CHANGES THAT FOSTER PRIMORDIAL PREVENTION
An integrated health care system in which many or most contacts for primordial prevention were with specially trained nonphysicians, generally by means other than office visits, such as phone calls, would provide greater convenience in achieving the goals of primordial prevention. Specially trained nonphysicians, most of whom have nursing degrees, have mastered a set of behaviorally oriented skills that renders them at least as effective as physicians as change agents.
Primary prevention, as provided by vertically integrated medical centers, can be coordinated efficiently with other aspects of care provided by generalist and specialist physicians. This coordination is facilitated by the computer, phone, mail, and other communications linkages noted above. The hospital-based smoking cessation program cited above is an example of communityoriented primary prevention.
FINANCIAL CHANGES THAT FOSTER PRIMORDIAL PREVENTION
Prevention may increasingly be mandated by employer-driven quality assurance processes such as HEDIS 2.0 (Health Plan Employer and Data Information Set) developed by the National Committee for Quality Assurance [11]. Health plans that do not offer primary prevention may find themselves at a competitive disadvantage in the medical marketplace. Even without the impetus of employer mandates, health care providers are increasingly turning to prevention to attract a broader patient base. More cost-effective methods of primary prevention may stimulate renewed interest in prevention among health care providers. For example, smoking cessation counseling by nonphysicians provided during hospitalization and followed by postdischarge phone contacts has demonstrated 1-year quit rates of nearly 30 to 40% among a general population of patients [5]. This approach may be more cost effective than prevention offered during routine outpatient visits.
REFERENCES 1. Starr P. The social transformation of American medicine. New York: Basic Books, 1982. 2. Kottke TE, Battista RN, DeFriese GH, Brekke ML. Attributes of successful smoking cessation interventions in medical practice: a meta-analysis of 39 controlled trials. JAMA 1988;259:2883–9. 3. Taylor CB, Houston Miller N, Killen JD, DeBusk RF. Smoking cessation after acute myocardial infarction: effects of a nursemanaged intervention. Ann Intern Med 1990;113:118–23. 4. DeBusk RF, Miller NH, Superko HR, Dennis CA, Thomas RJ. Lew HT, et al. A case management system for coronary risk factor modification following acute myocardial infarction. Ann Intern Med 1994;120:721–9. 5. Taylor CB, Houston Miller N, Herman S, Smith PM, Dobel D, Fisher L, et al. A nurse-managed smoking cessation program for hospitalized smokers. Am J Public Health 1997;86:1557–60. 6. Orleans CT, Christeller JL, Gritz ER. Helping hospitalized smokers quit: new directions for treatment and research. J Consult Clin. Psychol 1993;61:778–9. 7. Orleans CT, Ockene JK. Routine hospital-based quit-smoking
HEALTH CARE SYSTEM IN PRIMORDIAL PREVENTION treatment for the post-myocardial infarction patient: an idea whose time has come. J Am Coll Cardiol 1993;22:1703–5. 8. Schauffler HH, Rodriguez T. Exercising purchasing power for preventive care. Health Affairs 1995;15:73–85. 9. Weinstein MC. Economics of prevention. J Gen Intern Med 1990;5 Suppl:S89–S92.
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10. Smith PM, Houston Miller N, Taylor CB, DeBusk RF. Cost effectiveness of a smoking cessation program in hospitalized patients [Manuscript in preparation]. 11. National Committee for Quality Assurance. Health Plan Employer Data and Information Set (HEDIS), Version 2.0. Washington: NCQA, 1993 Oct.