Public Release: 

January/February 2017 Annals of Family Medicine tip sheet

American Academy of Family Physicians

In this issue, the National Commission on Prevention Priorities publishes a much anticipated update to its 2006 ranking of clinical preventive services. The report uses microsimulation modeling to demonstrate the relative health impact and cost-effectiveness of preventive services for which there is strong evidence of effectiveness. These findings can be used by individuals, practices and policy makers to focus attention on the preventive services that are most likely to make a difference. The new rankings come at a pivotal time in the changing health care landscape--when access to and uptake of preventive care services is expanding, when clinician time and resources are constrained, and amid a shift to a pay-for-value paradigm.

In addition to the updated rankings, the issue features a cluster of five related research articles and commentary. Two research articles use microsimulation analyses to identify which preventive options for cardiovascular disease are most effective and to examine the impact of tobacco counseling for youth and adults. Accompanying editorials by former Surgeon General David Satcher, MD, PhD, and research analysts at HealthPartners Institute, which developed the methodology to rank clinical preventive services for the NCPP, provide helpful perspective in understanding this new information and in applying it in policy and practice.

National Commission on Prevention Priorities Releases New Rankings of Clinical Preventive Services Last Updated in 2006

The National Commission on Prevention Priorities updates its 2006 rankings of 28 clinical preventive services for which the U.S. Preventive Services Task Force and the Advisory Committee on Immunization Practices have found strong evidence of effectiveness. Working with HealthPartners Institute, the Commission used sophisticated microsimulation modeling to estimate the relative health impact and cost-effectiveness of each service. The findings, which reflect changes in the evidence base and recommendations for clinical preventive services and a vastly changed health care environment, are intended to assist health care providers and other decision makers in their efforts to plan quality improvement initiatives, develop performance measurements, build primary care medical homes, and incorporate preventive services into the contracts of accountable care organizations. In-depth analyses found the three highest ranking services, each with a total score of 10 (out of a total possible score of 10), are immunizing children, counseling to prevent tobacco initiation among youth, and tobacco-use screening and brief intervention to encourage cessation among adults. Other high-ranking services with scores of six and above include: alcohol misuse screening with brief intervention (8), discussing aspirin use with high-risk adults (8), colorectal cancer screening (8), cervical cancer screening (8), chlamydia and gonorrhea screening (7), cholesterol screening (7), hypertension screening (7), obesity screening (6), healthy diet counseling for those at a higher risk of cardiovascular disease (6), abdominal aortic aneurysm screening in high risk men (6), HIV screening (6), human papillomavirus immunization (6), influenza immunization (6), syphilis screening (6), and vision screening for children (6). Writing that the NCPP has always maintained an emphasis on high-value clinical preventive services, the authors note that since 2001, only six recommended preventive services changed their score by more than one point, a finding that should reassure providers and health systems that expend substantial energy and resources to incorporate these rankings into quality improvement efforts. Based on their analysis of actual utilization, the authors conclude there remains substantial opportunity for primary care to improve population health through increased implementation of these evidence-based services.

Updated Priorities Among Effective Clinical Preventive Services
By Michael V. Maciosek, PhD, et al
HealthPartners Institute, Minneapolis, Minnesota

Editorials: Understanding and Applying the Updated Rankings from the National Commission on Preventive Priorities

Three accompanying editorials provide complimentary and useful perspectives in understanding the NCPP rankings and applying them in policy and practice.

In the first editorial, David Satcher, MD, PhD, former U.S. Surgeon General and founding director of the Satcher Health Leadership Institute at Morehouse School of Medicine, writes that the 2016 NCPP rankings come at a pivotal time given the changing health and health care landscape. He asserts the need to use a systematic, rational approach to prioritize the delivery of evidence-based health care services has only grown, pointing to the health care sector's evolution from a fee-for-service health care payment system to a pay-for-value paradigm, as well as the Patient Protection and Affordable Care Act, which increased access to care for millions and allowed for no-cost, out-of-pocket preventive services coverage. He concludes the NCPP ranking of clinical preventive services is an invaluable translational guide for delivering recommended quality services, improving the health of individuals, eliminating health disparities and using resources responsibly. He notes that by simply closing the significant gaps in delivery of high-ranking preventive services, today's clinicians could add many more healthy years to the lives of patients.

An editorial by George Isham, MD, MS, and colleagues elucidates the value of the NCPP's rankings in a health care environment where time and resources are limited. They discuss how the rankings can inform the choices of clinicians, patients, health plans and policy makers alike. At a time when office visits are too brief, and the time allotted for preventive services shorter still, the rankings allow clinicians to sequentially deliver the highest value interventions appropriate to each patient to help ensure time is well spent and patients are well served. At the health plan level, the rankings can inform priorities that influence the direction of quality improvement initiatives and pay-for- performance programs. Patients can use the rankings to better understand what care is most beneficial to them and their family members, empowering them to demand evidence-supported care from their health care providers. The rankings also can guide the decisions of policy makers who determine the requirements of measurement and reporting for preventive services to ensure they reflect the services with the highest impact and strongest evidence base.

In a third editorial, Patrick J. O'Connor, MD, MA, MPH, and colleagues from HealthPartners Institute outline strategies for prioritizing clinical options in primary care. They explain why it is beneficial to prioritize clinical services at the patient level and assert that while primary care clinicians have traditionally prioritized treatment options intuitively, intuitive estimation of the potential benefit of multiple clinical options is very challenging and often not accurate. They elucidate the potential of electronic health records and clinical decision support systems for identifying and prioritizing clinical options. EHR-linked, web-based, real-time clinical decision support systems, they write, facilitate patient-centered care and shared decision making by informing patients of clinical options with the most potential benefit and then empowering patients to select their preferred options. Advances in health care informatics and risk prediction methods, they conclude, will enable the design of new and more effective strategies and systems that will have higher use rates, higher clinician satisfaction, and will improve patients' clinical outcomes.

Preventive Interventions: An Immediate Priority
By David Satcher, MD, PhD
Morehouse School of Medicine, Atlanta, Georgia

Prevention Priorities: Guidance for Value-Driven Health Improvement
By George Isham, MD, MS, et al
HealthPartners Institute, Minneapolis, Minnesota

Strategies to Prioritize Clinical Options in Primary Care
By Patrick J. O'Connor, MD, MA, MPH, et al
HeathPartners Institute, Minneapolis, Minnesota

Tobacco Counseling Results in More Meaningful Improvements in Population Health Than Almost Any Other Preventive Service

Despite recent reductions in the prevalence of adult smoking, 42 million adults continue to smoke, and in 2015, 1.6 million middle- and high-school students self-reported smoking tobacco in the last 30 days. Smoking is still the leading cause of preventable death in the United States, and the direct medical costs of smoking are about $175 billion per year. Against this backdrop, researchers at HealthPartners Institute employed sophisticated micosimulation analyses to assess the long-term value of providing brief, annual tobacco counseling to both youth and adults over the lifetimes of a U.S. birth cohort of 4 million persons. They find that brief tobacco counseling provides substantial health benefits while producing cost savings and is therefore a high-priority use of limited clinician time. Specifically, modeling showed that compared with no tobacco counseling, annual counseling for youth would reduce the average prevalence of smoking cigarettes during adult years by two percentage points. Annual counseling for adults would reduce prevalence by 3.8 percentage points. Youth counseling would prevent 42,686 smoking-attributable fatalities and increase quality-adjusted life years by 756,501 over the lifetime of the cohort. Adult counseling would prevent 69,901 smoking-attributable fatalities and increase QALYs by 1,044,392. Youth and adult counseling would yield net savings of $225 and $580 per person, respectively. If annual tobacco counseling was provided to the cohort during both youth and adult years, then adult smoking prevalence would be 5.5 percentage points lower compared with no counseling, and there would be 105,917 fewer smoking-attributable fatalities over their lifetimes. They note that at current rates, only one-third of the potential health and economic benefits of counseling are being realized, demonstrating a significant delivery gap. The authors conclude these findings demonstrate tobacco counseling can produce more meaningful improvements in population health with good stewardship of health care system resources than almost any other preventive service.

Health Benefits and Cost-Effectiveness of Brief Clinician Tobacco Counseling for Youth and Adults
By Michael V. Maciosek, PhD, et al
HealthPartners Institute, Minneapolis, Minnesota

Aspirin Counseling and Screening for Hypertension and High Cholesterol Among Most Beneficial and Cost-Effective Preventive Services

Cardiovascular disease is the leading cause of death and among the greatest causes of morbidity in the United States today, with total direct and indirect costs estimated to exceed $300 billion annually and total direct medical costs projected to triple by 2030.

Given the prevalence and burden of CVD, researchers at HealthPartners Institute used microsimulation modeling to update estimates of the health and economic impact of three services recommended for the prevention of CVD, including cholesterol screening, lipid screening and aspirin counseling. They find all three services continue to rank highly among other recommended preventive services for U.S. adults in primary care. Specifically, comparing lifetime outcomes from a societal perspective for a U.S. birth cohort of 100,000 persons, they found health impact is highest for hypertension screening and treatment (15,600 quality-adjusted life years), but is closely followed by cholesterol screening and treatment (14,300 QALYs). Aspirin counseling has lower health impact (2,200 QALYs), but was found to be cost saving ($31 saved per person). They found cost-effectiveness for cholesterol and hypertension screening and treatment is $33,800 per QALY and $48,500 per QALY, respectively. Sophisticated modeling revealed that population subgroup outcomes sometimes diverged in meaningful ways from the population average. For example, findings favored hypertension over cholesterol screening for women, and opportunities to reduce disease burden across all services are greatest for the non-Hispanic black population. The authors conclude these findings demonstrate that clinical services for the primary prevention of CVD can avert substantial disease burden and save costs and should remain among the top prevention priorities for adults in primary care. Individual priorities should be tailored into practice by taking a patient's demographic characteristics and clinical objectives into account.

Health Benefits and Cost-Effectiveness of Asymptomatic Screening for Hypertension and High Cholesterol and Aspirin Counseling for Primary Prevention
By Steven P. Dehmer, PhD, et al
HealthPartners Institute, Minneapolis, Minnesota

Primary Care Physician Involvement at the End of Life Associated with Less Costly and Less Intensive End-of-Life Care

Regions of the country with greater primary care physician involvement in the last six months of life appear to have lower-intensity, lower-cost end-of-life care. Analyzing 2010 Medicare Part B claims data for 306 U.S. hospital reference regions, capturing 1,107,702 beneficiaries with chronic disease who died, researchers found chronically ill adults living in regions with greater primary care physician involvement experienced less intensive care unit care in their last six months of life and were less likely to have more than 10 physicians in their care. Additionally, these regions had less costly end-of-life care, despite lower rates of hospice use. Specifically, they found HRRs with the greater primary care involvement had lower Medicare spending in the last two years of life ($65,160 vs. $69,030) and fewer ICU days in the last six months of life (2.9 vs. 4.3) but also less hospice enrollment (45 percent vs. 50 percent of decedents). The authors offer several possible explanations for the paradoxical finding that greater primary care physician involvement is associated with less hospice use. The authors conclude these findings can help us better understand and optimize the role of primary care physicians in care at the end of life in order to both improve the care of the dying and reduce unnecessary and costly intensive care.

Regional Variation in Primary Care Involvement at the End of Life
By Claire K. Ankuda, MD, MPH, et al
Robert Wood Johnson Clinical Scholars Program, University of Michigan Health System, Ann Arbor

Survey: Most Breastfed Infants Not Receiving Recommended Vitamin D Supplementation; Mothers Prefer Maternal Over Infant Supplementation

Although daily vitamin D supplementation is recommended for breastfed infants, adherence to this recommendation is poor. Researchers at the Mayo Clinic explored maternal preferences for vitamin D supplementation and found less than half of infants in the study were receiving the recommended daily vitamin D supplementation. Given a choice, most mothers would prefer to supplement themselves to enrich their breast milk with vitamin D rather than supplement their infants. Surveying 140 mothers with exclusively breastfed infants and 44 who used both breast milk and formula milk, researchers found only 55 percent supplemented their infants with vitamin D, and only 42 percent supplemented with the 400 IU recommended. Regarding maternal preferences, they found 88 percent of mothers preferred supplementing themselves rather than their infants, and 57 percent preferred daily to monthly supplementation. Mothers cited safety as most important in choosing a method of supplementation. The authors conclude that taking maternal preferences into consideration could improve adequate intakes of vitamin D in breastfed infants. They offer that because most mothers take a prenatal vitamin after delivery, higher doses of vitamin D (4000-6400 IU daily) could be incorporated into the maternal supplementation routine to enrich the breast milk with vitamin D. They cite ease of administration and avoidance of potential toxicity to the infant from dosing errors as advantages of maternal rather than infant supplementation.

Maternal Preferences for Vitamin D Supplementation in Breastfed Infants
By Tom D. Thacher, MD, et al
Mayo Clinic, Rochester, Minnesota

Substantial Increases in Health Information Technology Adoption Among Small Primary Care Practices Between 2007 and 2013 With Largest Gains in Larger, Hospital-Owned Practices

Uptake of health information technology by primary care practices is still far from universal, even though it serves as a foundational element for high-performing primary care. Seeking to better understand the correlates of greater health information technology implementation, researchers analyzed data from telephone surveys of 566 small primary care practices with eight or fewer physicians in 2007-2010 and 2012-2013. They found increases over the time period in 16 out of 18 measures of health information functionality, with the largest gains among hospital-owned practices, practices with three to eight versus one to two physicians, practices with more Medicare patients, and those participating in pay-for-performance or public reporting of quality data. Specifically, they found physician use of electronic health records to collect quality data increased from 17 percent to 42 percent and e-prescribing increased from 25 percent to 70 percent over time. Examining the association of practice characteristics and external incentives with the adoption and use of HIT, they found hospital-owned practices used on average 1.5 more HIT processes than physician-owned practices, and practices with three to eight physicians used 2.5 more HIT processes than smaller practices. External incentives (participation in pay-for-performance programs, participation in public reporting of clinical quality data, and greater proportion of revenue from Medicare) were also positively associated with greater adoption and use of HIT, although the effect sizes were smaller. The authors note that despite the substantial increases in adoption and use of HIT, there remains ample room for improvement. Fewer than 50 percent of practices surveyed reported using most EHR functionalities. Only one in five practices used e-mail with patients or allowed patients to see their medical records online, and maintenance of electronic registries for the management of chronic disease was also low. The authors conclude that targeting assistance to smaller, physician-owned practices and offering payment incentives and technical support would help encourage uptake and use of HIT in primary care.

Increased Health Information Technology Adoption and Use Among Small Primary Care Physician Practices Over Time: A National Cohort Study
By Diane R. Rittenhouse, MD, MPH, et al
University of California, San Francisco

Video Decision Aids Effective in Changing Mammography and Prostate Cancer Screening Intentions

Researchers tested novel video decision aids designed to help patients trust and accept the controversial U.S. Preventive Services Task Force recommendations against screening for prostate cancers with the prostate specific antigen test (from 2012) and that women in their 40s should make an informed choice about mammography (from 2009). They found that while a more traditional, print (control) decision aid had no effect on the screening intentions of participants, recorded video vignettes of physician-patient discussions about the screening recommendations significantly changed the screening intentions of a substantial proportion of participants. At entry, 86 percent of the 35 women who participated in the study reported wanting screening, 6 percent were unsure, and 9 percent did not want screening. At the study end, 49 percent of the women wanted screening, 20 percent were unsure, and 29 percent did not want screening. At baseline, 69 percent of the 27 men who participated in the study reported wanting prostate screening, and 31 percent were unsure. After exposure to both interventions, 33 percent wanted screening, 11 percent were unsure, and 56 percent did not want screening. Specifically, mean change on a three-point, yes, unsure, no scale was -0.93 (P = .0002) for men and -0.50 (P = .0007) for women after seeing the video interventions vs. 0.0 and -0.06 (P = NS) after seeing the print interventions. The authors note while this novel, persuasive video approach needs further testing, these findings are far more promising than those previously reported for many other decision aids and may serve as a template for the development of persuasive interventions for helping patients consider and accept evidence-based, counterintuitive recommendations and reduce use of low-value procedures.

Persuasive Interventions for Controversial Cancer Screening Recommendations: Testing a Novel Approach to Help Patients Make Evidence-Based Decisions
By Barry G. Saver, MD, MPH, et al
University of Massachusetts Medical School, Worcester

Editorial: Family Physicians Can Help Heal a Divided Nation

Two family physicians reflect on the 2016 U.S. elections, which revealed deep schisms based on race and social class. They assert that family physicians are uniquely positioned to help heal the divisions because, more than any other medical specialty, they practice in communities that reflect the geographic distribution of the nation's overall population. In order to heal divisions and build bridges between the diverse communities in which they live and practice, they propose family physicians commit to four actions: 1) explore the roots of their implicit prejudices by examining their privilege, fostering workplace conversations to address discrimination, and challenging institutions and policies that propagate implicit bias; 2) model inclusivity by fostering welcoming, inclusive and safe places for patients, staff and trainees; 3) deploy strategies in the clinical setting to address the social determinants of heath; and 4) advocate for health in a world of competing political priorities.

Perspectives in Primary Care: Family Medicine in a Divided Nation
By Max J. Romano, MD, MPH, and Kevin Grumbach, MD
Johns Hopkins University, Baltimore, Maryland, and University of California, San Francisco

Performance Measurement: Applying Lessons From the World of Public Education to Health Care

Two researchers, one with a background in education policy and the other in primary care, outline how outcomes measurement and public reporting of quality data in public education can serve as both a positive example and a cautionary tale for similar changes in that are underway two decades later in health care. They contend that performance measurement techniques can be useful if properly applied, and they advise physicians to learn from teachers that opposition will not cause such efforts to go away. They caution health policy leaders to not discount the expertise of physicians in the heavy-handed way that educational policy leaders have in the case of teachers, focusing on a narrow list of outcomes; rather, they should recognize the limitations of business models in service sectors, reconnect with local communities, and more effectively listen to their voices. The unintended consequences of poorly implemented performance management in both education and health care, they assert, include the narrowing of purpose, deprofessionalization and a loss of community control.

Measuring Outcomes: Lessons From the World of Public Education
By Andrew Saultz, PhD, and John W. Saultz, MD
Miami University, Oxford, Ohio, and Oregon Health & Science University, Portland

Reflection: The Importance of Mutual Gaze in Early Infant Brain Development
Why Current Standards for "Early Intervention" for Autism Spectrum Disorder May Not Be Early Enough

A family physician uses recent neuroscience findings to examine how mutual gaze between a mother and her newborn critically impacts early infant brain development and may offer critical lessons for helping prevent Autism Spectrum Disorders. Reflecting on a well-visit wherein a new mother expressed concern that her 4-month old was "staring into blank space," he explains whys he counsels his new parents to hold their infants close, encourage efforts to babble and coo, be mindful of opportunities for mutual play, and encourage the basic innate joy in their interactions with their babies. He asserts that mutual gaze is a deeply ingrained mechanism for the development of important parts of the brain and allows for a healthy integration of self through the transmission and regulation of emotion. Because new parents are closest to their babies, it is mainly their gaze interactions during brief joyful moments that serve to develop the infant's own sense of self. Ungar concludes that family physicians can impact the lives of their littlest patients in meaningful ways, possibly even helping to reduce the incidence of Attention Deficit Hyperactivity Disorder and Autism Spectrum Disorders, by sharing this powerful insight during well-infant and post-partum visits. He notes that current models for "early intervention" for Autism Spectrum Disorder in family medicine target preschool age children, but the problem may be originating at a critical window of development that is far earlier - immediately after birth.

Neuroscience, Joy, and the Well-Infant Visit That Got Me Thinking
By Tamas Ungar, MD
St. Anthony's Hospital/Franciscan Health System, Gig Harbor, Washington

Physician and Rape Survivor Reflects on How Clinicians Can Help Facilitate Healing Among Survivors of Sex Violence

A rheumatologist shares her experience as a survivor of sexual violence and as a provider for patients whose wounds from these traumas have flourished in atmospheres of shame and stigma. In a courageous essay, Volkmann's deeply personal insights demonstrate how physicians and other health care providers can play a central role in restoring the health of individuals who silently suffer sexual assault.
Silent Survivors
By Elizabeth R. Volkmann, MD, MS
University of California, Los Angeles

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Annals of Family Medicine is a peer-reviewed, indexed research journal that provides a cross-disciplinary forum for new, evidence-based information affecting the primary care disciplines. Launched in May 2003, Annals is sponsored by seven family medical organizations, including the American Academy of Family Physicians, the American Board of Family Medicine, the Society of Teachers of Family Medicine, the Association of Departments of Family Medicine, the Association of Family Medicine Residency Directors, the North American Primary Care Research Group, and the College of Family Physicians of Canada. Annals is published six times each year and contains original research from the clinical, biomedical, social and health services areas, as well as contributions on methodology and theory, selected reviews, essays and editorials. Complete editorial content and interactive discussion groups for each published article can be accessed free of charge on the journal's website, http://www.annfammed.org.

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