dr. woolf presentation

8/19/2019 Dr. Woolf Presentation

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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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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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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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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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Special interests,

profit motivesGovernment intrusion

The need to insulate

science from politics


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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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