Priorities among recommended clinical preventive services.

BACKGROUND: Many recommended clinical preventive services are delivered at low rates. Decision-makers who wish to improve delivery rates, but face competing demands for finite resources, need information on the relative value of these services. This article describes the results of a systematic assessment of the value of clinical preventive services recommended for average-risk patients by the U.S. Preventive Services Task Force. METHODS: The assessment of services' value for the U.S. population was based on two dimensions: burden of disease prevented by each service and cost effectiveness. Methods were developed for measuring these criteria consistently across different types of services. A companion article describes the methods in greater detail. Each service received 1 to 5 points on each of the two dimensions, for total scores ranging from 2 to 10. Priority opportunities for improving delivery rates were determined by comparing the ranking of services with what is known of current delivery rates nationally. RESULTS: The highest ranked services (scores of 7+) with the lowest delivery rates (< or =50% nationally) are providing tobacco cessation counseling to adults, screening older adults for undetected vision impairments, offering adolescents an anti-tobacco message or advice to quit, counseling adolescents on alcohol and drug abstinence, screening adults for colorectal cancer, screening young women for chlamydial infection, screening adults for problem drinking, and vaccinating older adults against pneumococcal disease. CONCLUSIONS: Decision-makers can use the results to set their own priorities for increasing delivery of clinical preventive services. The methods provide a basis for future priority-setting efforts.     

Methods for priority setting among clinical preventive services.

Methods used to compare the value of clinical preventive services based on two criteria-clinically preventable burden (CPB) and cost effectiveness (CE)-are described. A companion article provides rankings of clinical preventive services and discusses its uses for decision-makers; this article focuses on the methods, challenges faced, and solutions. The authors considered all types of data essential to measuring CPB and CE for services recommended by the U.S. Preventive Services Task Force and developed methods essential to ensuring valid comparisons of different services' relative value.     

Disability and receipt of clinical preventive services among women

BACKGROUND: More individuals are surviving catastrophic injuries and living longer with persistent disability; however, their receipt of clinical preventive services is not well understood as compared with those without disabilities given the dual focus of care on both primary prevention and the prevention of secondary complications related to their disabilities. METHODS: Longitudinal analyses of 1999-2002 Medical Expenditure Survey (MEPS). Study sample consisted of 3,183 community-dwelling women aged 51-64 years and followed for 2 full years. Women with disabilities were defined as having reported any limitation in any area of activity of daily living in 2 years. Recommended clinical preventive services were defined as receiving the following at the recommended intervals: colorectal, cervical, and breast cancer; cholesterol screening; and influenza immunization. chi(2) tests and multiple logistic regressions were used to examine variations in use of clinical preventive services. RESULTS: Overall, 23% of the women in the study (n = 835) were disabled. Disabled women, however, were less likely to receive mammography and Pap smears within the recommended intervals. However, disabled women were more likely to receive influenza immunization, cholesterol screening, and colorectal screening within the recommended intervals. Among the disabled, usual source of care and health insurance remained significant predictors of receipt of clinical preventive services across all types, CONCLUSIONS: Disabled women were less likely to receive some of the cancer screening services, suggesting a need for targeted interventions to promote breast cancer and cervical cancer screening. Increased access to health care insurance and health care providers may also help.     

Awareness and utilization of preventive care services among the elderly under National Health Insurance

This empirical study investigates the factors affecting the awareness and the utilization of preventive care among the elderly in Taiwan. We use data obtained from the 2005 National Health Interview Survey. A recursive bivariate probit model is adopted to analyze the factors affecting the awareness and the utilization of preventive care. The probability of awareness of free preventive care under the National Health Insurance is higher for those who are younger, Mainlanders, have received more education, have a spouse, exercise regularly, have better self-rated health status, and have chronic diseases; the probability of awareness is lower for those who are aborigines and who live in the south and the east. Awareness of preventive care services, having a spouse, living alone, having better health status, and the existence of chronic diseases increase the probability of preventive care utilization; working reduces the probability of preventive care utilization. Our result supports the views in Arrow (Am Econ Rev 53(5):941–973, 1963) that health information is an important factor determining the demand for medical care. Policymakers may enhance such preventive care service utilization by increasing the awareness of such services among the elderly.     

Employer coverage of clinical preventive services in the United States

PURPOSE: To characterize employers' coverage of clinical preventive services. DESIGN: Mercer Human Resource Consulting Inc. included questions on clinical preventive services as part of its National Survey of Employer-Sponsored Health Plans, 2001. SETTING: A national sample of employers of a large, medium, and small number of employees, including governments. SUBJECTS: Respondents self-identified as most knowledgeable about the organization's health benefits. MEASURES: Weighted analyses of responses to eight survey questions on health promotion. RESULTS: The survey was completed by 2180 employers, and the response rate was 21%. More than 90% of employers included increased productivity and decreased health care costs among their most important reasons for coverage of clinical preventive services. Within health insurance, coverage of physical examinations, immunizations, and screenings generally exceeded 50%, but coverage of lifestyle modification services was less than 20%. Only 20% of employers covered tobacco cessation services, and only 4% of employers provided an "optimal" benefit. We compared employers' offerings with a published ranking, by impact and value, of clinical preventive services. We found the biggest discrepancy in tobacco cessation services and alcohol problem prevention, which ranked high in terms of impact and value but are offered by only 20% and 18% of employers, respectively. CONCLUSIONS: Employers seek financial return from their offerings of clinical preventive services to employees, but they are least likely to offer the services most likely to provide this return.     

Priorities among effective clinical preventive services: methods

Decision makers want to know which healthcare services matter the most, but there are no well-established, practical methods for providing evidence-based answers to such questions. Led by the National Commission on Prevention Priorities, the authors update the methods for determining the relative health impact and economic value of clinical preventive services. Using new studies, new preventive service recommendations, and improved methods, the authors present a new ranking of clinical preventive services in the companion article. The original ranking and methods were published in this journal in 2001. The current methods report focuses on evidence collection for a priority setting exercise, guidance for which is effectively lacking in the literature. The authors describe their own standards for searching, tracking, and abstracting literature for priority setting. The authors also summarize their methods for making valid comparisons across different services. This report should be useful to those who want to understand additional detail about how the ranking was developed or who want to adapt the methods for their own purposes.     

Comparison of utilization of preventive health care services between two racial populations

PURPOSE: The difference in utilization of existing preventive health care services (PHCS) may be related to race. We compared the difference in use of PHCS between black and white males in Northwest Louisiana.METHODS: A cross-sectional survey regarding utilization of preventive health care services was conducted from 09/93-10/97. Approximate equal number of white and black males participated in this quota survey.RESULTS: 70% of black males said they had ever gone to the doctor for routine preventive check-up, while 79% of white males did so (p < 0.001). For those who previously had a routine preventive check-up, 88% had their last one within one year. Most routine check-ups are provided as part of the employment. The white males are 1.4 times more likely to have a routine check-up as compared to black males (p < 0.05). Factors which have a positive effect on use of PHCS are education (OR = 1.07, p < 0.01); intent to get a check-up (OR = 9.0, p < 0.001); the doctor spending enough time with the patients (OR = 2.4, p = 0.01); and wanting some health information (OR = 1.7, p < 0.001). Factors which have a negative effect on use of PHCS are cost (OR = 0.73, p = 0.046); having to go to different places (OR = 0.65, p = 0.024); and being scared of the doctor (OR = 0.46, p < 0.001). An indication of a negative effect-although not statistically significant-was found for long waiting time (OR= 0.73, p = 0.55) and the doctor not spending enough time explaining to patients (OR = 0.47, p = 0.054).CONCLUSIONS: White males that are more likely to use PHCS as compared to African-Americans. People of higher education with a positive intent and actively seeking health information are more likely to use PHCS. The more time the doctor spends with the participant, the more likely it is the participant will come for a routine check-up. The barriers for use of PHCS are cost, having to go to different places, and being scared of the doctor.     

Cost-sharing and provider choice.

Restoring financial incentives to encourage patients to shop for the lowest prices for medical care underlies current procompetitive health financing proposals. This paper analyzes the impact of one such financial incentive--cost-sharing in health insurance--on patients' provider shopping behavior. Using data from the 'Health Insurance Study', the relationship of cost-sharing with the specialty type of the primary care provider and with the costliness of the selected provider is investigated. The results were mixed as to whether patients who have only catastrophic coverage seek lower priced physicians than patients who have free care; however, any differences were small. Even among the well-educated, who are likely to be more efficient than the less educated at obtaining comparative price information, the effects of cost-sharing on the costliness of the selected medical care provider were minimal.     

The delivery of clinical preventive services: acute care intervention

BACKGROUND:. Evidence-based clinical preventive services are underutilized. We explored the major factors associated with delivery of these services in a large physician-owned community-based group practice that provided care for both fee-for-service (FFS) and health maintenance organization (HMO) patient populations. METHODS: We performed a cross-sectional audit of the computerized billing data of all adult outpatients seen at least once by any primary care provider in 1995 (N = 75,621). Delivery of preventive services was stratified by age, sex, visit frequency, insurance status (FFS or HMO), and visit type (acute care only or scheduled preventive visit). RESULTS: Insurance status and visit type were the strongest predictors of clinical preventive service delivery. Patients with FFS coverage received 6% to 13% (absolute difference) fewer of these services than HMO patients. Acute-care-only patients received 9% to 45% fewer services than patients who scheduled preventive visits. The combination of these factors was associated with profound differences. CONCLUSIONS: Having insurance to pay for preventive services is an important factor in the delivery of such care. Encouraging all patients to schedule preventive visits has been suggested as a strategy for increasing delivery, but that is not practical in this setting. Assessing the need for preventive services and offering them during acute care visits has equal potential for increasing delivery.     

Improving delivery of clinical preventive services: a multi-year journey

BACKGROUND: Adults in the United States typically do not receive all recommended clinical preventive services (CPS) for which they are eligible, missing opportunities for prevention and/or early detection. A multi-year quality improvement initiative targeting CPS delivery in a fee-for-service ambulatory care network is described. METHODS: Since 1999, HealthTexas Provider Network (HTPN) has implemented multiple initiatives to increase CPS delivery, including a flowsheet, a physician champion model, physician- and practice-level audit and feedback, and rapid-cycle quality improvement training. RESULTS: From 2000 to 2006, "recommended or done" CPS delivery increased from 68% to 92%, and "done" from 70% to 86% (2001 to 2006). "Perfect care" composite performance increased from 0.19 to 0.51 (2001 to 2006). CONCLUSIONS: Long-term, multistrategy approaches can achieve substantial sustained improvement in CPS delivery throughout a large ambulatory care provider network.     

Parenting stress and the utilization of pediatric services.

Parents' level of stress as measured by the Parenting Stress Index is examined in relation to the utilization of pediatric medical services for children between the ages of 1 and 48 months. The six categories of medical services considered were: Well Visits, Sick Visits, Infections, Diarrhea and Vomiting, Traumatic Injuries, and Other Medical Services. For the first 18 months of age no significant mean difference between stress groups and medical utilization was found. Significant correlations and mean differences were found for the 19- to 24- and the 25- to 48-month age groups in relation to the traumatic injury criterion. Moderate parenting stress is interpreted as potentially adaptive in relation to reducing traumatic injuries.     

社区预防服务的需求和有偿服务需求意向分析

现有的社区预防服务已经不能完全满足居民的需要，居民的卫生服务需求侧重于慢性病防治、脆弱人群与家庭保健。价格合理的有偿服务在居民中有一定需求，这主要包括各种上门服务、各种预防性体检和筛查,城郊结合地区居民对有偿预防服务的需求最大；有偿签约服务的需求价格弹性为－4．19。