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NEWS & VIEWS |
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The study was conducted by the non-profit Partnership for Prevention, based in Washington, DC, an association of corporations, non-profit organiza-tions, and state health departments charged with analyzing health promo-tion and disease prevention issues. The study was supported by the US Centers for Disease Control and Prevention and the Health Care Financing Admin-istration.
The authors looked at 30 preventive health services the US Preventive Ser-vices Task Force recommends for Am-ericans at average risk of disease, from birth through death. The intention, says Ashley Coffield, MPA, co-author and research fellow with Partnership for Prevention, was to produce information that would guide developers of health plans, employers purchasing health insurance, and providers of health care to "good-value services" when they are dealing with limited time and money.
They calculated each service’s effect on clinically preventable burden of disease (CPB), a measure that reflects the disease, injury, and premature death prevented by the intervention and is expressed in quality-adjusted life years (QALYs). Based on this calculation, the authors assigned a score from one to five for each service, with a rank of five indicating the highest CPB. They then calculated the cost effectiveness (CE), defined as net cost (the cost of providing the service as recommended over a lifetime, minus the money saved by avoiding illness or injury) divided by the CPB. That, too, was assigned a score of one to five, with five indicating the most cost-effective services. The authors then ranked the services based on the sum of these two scores. Fourteen services scored seven or higher out of a possible 10. They finally looked at whether these top-scoring preventive services were available to most Americans. In eight of the 14 cases, they were not.
Physicians’ counseling of patients about tobacco was nearly as valuable as childhood immunizations. The burden of disease it prevents is so great, even moderately effective counseling makes a huge impact.
Among the top seven preventive services (based on their sum of CPB and CE) listed below, five (in bold type) are relevant to prevention and/or early detection of cancer:
65. 18 years. 65 years. In the rankings, physicians’ counseling of patients about tobacco was nearly as valuable (nine) as childhood immunizations (10), says Coffield. That finding, she says, may surprise physicians and the public alike, as it initially did her, "Because most people perceive tobacco counseling as effective, but not highly effective." And in fact, tobacco counseling isn’t highly effective in convincing smokers to quit, Coffield says—but because the burden of disease it prevents is so great, even moderately effective counseling makes a huge impact.
Coffield says some people are surprised that mammography is midway down the list, with a combined score of six and a rank of 16th among the 30 preventive services. "Mammography is a good deal, and we ought to be doing it, but some preventive services are even a better deal than mammography," she says. "And if we pay for mammography, we ought to pay for people to stop smoking."
Among the top 14 ranked services, eight had a delivery rate to the US population of 
50%. Five of these were relevant to cancer prevention or early detection:
65. 65 years. 65 years against pneumococcal disease. Coffield calls for employers to buy insurance policies that pay for preventive services and for health insurance companies to hold providers accountable for delivering these services. "There’s a big gap between covering it and providing it," she says.
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Danger of Either/Or |
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 TOP Danger of Either/Or |
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"Health care must not be characterized as a zero-sum game with the ability to quick-fix the generic problem by merely realigning priorities," says Bal.
"Moreover, the penchant to compare apples with oranges or bananas is inherent in any such modeling enterprise, because the quantification of both cost and benefit, in each intervention of interest, is under-standably subject to a whole slew of qualifiers or caveats," Bal notes.
"So, without in any way diminishing this worthy attempt at trying to prioritize these clinical preventive services, I feel that to use this prioritization directly for resource allocation decisions is premature at best," explains Bal. "Finally, it needs to be asked why these particular clinical preventive services were picked and why preventive services (that are historically under-financed) are often held to a more stringent litmus test of efficacy than other clinical interventions."
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