Medicare Now Covers Preventive Services

In a monumental shift to national health care insurance policy, The Affordable Care Act (ACA) started now covering preventive services (as opposed to solely treatment services). As of January 1, 2011, many preventive services are now covered under Medicare (and incentives given to states to be covered under Medicaid) if you get them from a doctor or other health care provider who accepts assignment.

 The services that qualify are listed below:

• Yearly wellness exam. If you are new to Medicare, your “Welcome to Medicare” physical exam is now covered without cost sharing during your first 12 months of Part B coverage (Initial Preventive Physical Examination or IPPE). This exam is a one-time review of your health as well as education and counseling about preventive services and other care.  If you’ve had Part B for longer than 12 months, you can get a yearly wellness visit (Annual Wellness Visit or AWV) to develop or update a personalized prevention plan based on your current health and risk factors.
• Tobacco use cessation counseling. This benefit is now considered a covered preventive service, whether or not you have been diagnosed with an illness caused or complicated by tobacco use.  While the counseling is a covered service, the co-insurance and deductible will apply if you have already been diagnosed with a tobacco related illness.
• Screening. No more Medicare Part B deductible or copayment for these screenings if certain coverage criteria apply:
• Bone mass measurement
• Cervical cancer screening, including Pap smear tests and pelvic exams
• Cholesterol and other cardiovascular screenings
• Colorectal cancer screening (except for barium enemas)
• Diabetes screening
• Flu shot, pneumonia shot, and the hepatitis B shot
• HIV screening for people at increased risk or who ask for the test
• Mammograms
• Medical nutrition therapy to help people manage diabetes or kidney disease
• Prostate cancer screening (except digital rectal examinations).                                                      

In addition, the Centers for Medicare Services has adopted or will be adopting all of the USPSTF A and B recommendations in order to be completely covered. For instance, The Centers for Medicare and Medicaid Services (CMS) has proposed to pay for "high intensity" obesity counseling for obese Medicare beneficiaries. In an effort to stem the tide of the growing obesity epidemic, CMS is proposing to pay covered seniors to undergo behavior modification and weight-loss counseling by a primary care practitioner, according to a proposed decision memo posted August 31 on the CMS web site. The counseling would involve one office visit every week for a month; one office visit every other week for months two to six; and one office visit for every remaining month through one year, provided that the patient has lost at least 6.6 lbs in the first six months. The counseling would have to take place in a primary care setting, such as a family physician's office, in order to be eligible for reimbursement from Medicare.

Take home message: With the advent of the Affordable Care Act, preventive medicine physicians are uniquely positioned specialists to be able to advise you and recommend appropriate preventive services that are uniquely tailored to your needs and risk factors.

Burden of Disease of Stroke

Stroke Burden of Disease

Prevalence:

Among adults age 20 and older, the estimated prevalence of stroke in 2006 was 6,400,000 (about 2,500,000 males and 3,900,000 females).

Incidence:

Each year about 795,000 people experience a new or recurrent stroke. About 610,000 of these are first attacks, and 185,000 are recurrent attacks.

• On average, every 40 seconds someone in the United States has a stroke.

• Each year, about 55,000 more women than men have a stroke.

• Men’s stroke incidence rates are greater than women’s at younger ages but not at older ages. The male/female incidence ratio is 1.25 at ages 55–64; 1.50 for ages 65–74; 1.07 at 75–84 and 0.76 at 85 and older.

Of all strokes, 87 percent are ischemic, 10 percent are intracerebral hemorrhage, and 3 percent are subarachnoid hemorrhage.

Mortality:

Stroke accounted for about one of every 18 deaths in the United States in 2006. Stroke mortality for 2006 was 137,119 (54,524 males, 82,595 females).

When considered separately from other cardiovascular diseases, stroke ranks No. 3 among all causes of death, behind diseases of the heart and cancer.

On average, every four minutes someone dies of a stroke.

Among people ages 45–64, 8 to 12 percent of ischemic strokes and 37 to 38 percent of hemorrhagic strokes result in death within 30 days, according to the ARIC study of the NHLBI.

Because women live longer than men and stroke occurs at older ages, more women than men die of stroke each year. Women accounted for 60.6 percent of U.S. stroke deaths in 2006.

Take home message: Stroke is the third leading cause of death in the US. It is over 80% preventable as most of its risk factors are modifiable (high blood pressure, exercise and diet).

Evidence for Prevention of Heart Disease -Does Eating Right, Exercising and Quitting Smoking Really Work?

One would argue that if we were to hedge our bets on what will be the most likely cause of our death, heart disease would be a safe bet. In addition, as pointed above, in half of heart disease deaths, there are few warning signs and hence the high prevalence of sudden cardiac death. It is therefore paramount to work with our doctors to do everything we can to prevent heart disease. The good news is that there is ample evidence that if we do the right things, we can prevent heart disease.

We have touched on the importance of risk factors in general, but about heart disease specifically?

A study of men and women in three prospective cohort studies found that about 90 percent of CHD patients have prior exposure to at least one of the following major risk factors: high total blood cholesterol levels, or current medication with cholesterol lowering drugs, hypertension, or current medication with blood pressure lowering drugs, current cigarette use, and clinical report of diabetes. (JAMA. 2003;290:891–897.)

According to a case-control study of 52 countries (INTERHEART), nine easily measured and potentially modifiable risk factors account for over 90 percent of the risk of an initial acute myocardial infarction (MI). The effect of these risk factors is consistent in men and women across different geographic regions and by ethnic group, making the study applicable worldwide. These nine risk factors include cigarette smoking, abnormal blood lipid levels, hypertension, diabetes, abdominal obesity, a lack of physical activity, low daily fruit and vegetable consumption, alcohol over-consumption and psychosocial

index. (Lancet. 2004;364:937–952.)

Similar results have been shown by the Chicago Heart Association Detection Project in Industry, the Framingham Heart Study, the Atherosclerosis Risk in Communities Study, the Multiple Risk Factor Intervention Trial (MRFIT) Study, the Chicago Heart Association Detection Project, The Nurses’ Health Study, the Health Professionals Follow-up Study and The NHANES II Mortality Follow-Up Study.

What is the evidence for lifestyle modification interventions?

The Lifestyle Heart Trial (Ornish) provided conclusive evidence that intensive lifestyle changes can regress coronary atherosclerosis (Ornish D, et al. Can lifestyle changes reverse coronary heart disease? The Lifestyle Heart Trial. Lancet 1990 Jul 21;336(8708):129-33.)

The Multicenter Lifestyle Demonstration Project showed that significant improvements in diet (low fat, whole foods, plant-based), exercise, stress management, and social support can be achieved and maintained in heart disease patients, especially with spousal participation (Koertge J, et al. Improvement in medical risk factors and quality of life in women and men with coronary artery disease in the Multicenter Lifestyle Demonstration Project. Am J Cardiol. 2003 Jun 1;91(11):1316-22.)

A systematic review found that 4 lifestyle changes can affect mortality risk in CVD patients (Iestra JA, Kromhout D, van der Schouw YT et al. Effect Size Estimates of Lifestyle and Dietary Changes on All-Cause Mortality in Coronary Artery Disease Patients, A Systematic Review. Circulation. 2005;112:924- 934).

_ smoking cessation -- a 36% reduction in mortality risk

_ increased physical activity -- a 24% reduction in mortality risk

_ moderate alcohol use -- a 20% reduction in mortality risk 

_ dietary changes -- a 44% reduction in mortality risk

A review of literature examining interventions to assist patients in achieving risk factor reductions through lifestyle change after myocardial infarction or coronary artery revascularization found that evidence supports: frequent follow-up, intensive diet changes, individualized and group exercise, coaching, group meetings, education on lifestyle modification and behavior change, and formal cardiac rehabilitation programs (Cobb SL, Brown DJ, Davis LL. Effective interventions for lifestyle change after myocardial infarction or coronary artery revascularization. J Am Acad Nurse Pract. 2006 Jan;18(1):31-9.)

Diet:

The Lyon Heart Study showed that a Mediterranean-type diet (which focuses on consumption of good fats, fruits, vegetables and whole grains) reduced cardiac death and non-fatal myocardial infarctions by 32% as compared to a typical “Western” diet (de Lorgeril M, Salen P, Martin JL, Monjaud I, Delaye J, Mamelle N. Mediterranean diet, traditional risk factors, and the rate of cardiovascular complications after myocardial infarction: final report of the Lyon Diet Heart Study. Circulation. 1999;99:779-785.

Smoking:

Several studies have shown that quitting smoking improves longevity and reduces recurrent heart related adverse events (Rippe JM, Angelopoulos TJ, Zukley L. The Rationale for Intervention to Reduce the Risk of Coronary Heart Disease. American Journal of Lifestyle Medicine 2007 1: 10-19.)

A systematic review of the effects of individual counseling on smoking cessation showed that individual counseling for 6 months or longer resulted in a 1.6 times greater likelihood of successful cessation (Lancaster T, Stead LF. Individual behavioural counselling for smoking cessation. Cochrane Database Syst Rev. 2002;(3)CD001292).

Exercise:

Several systematic reviews have shown the importance of exercise for patients with CVD (Taylor RS, Brown A, Ebrahim S et al. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med 2004; 116: 682-92.)

A prospective study of 773 men with known CAD followed for 5 years showed that those who engaged in light and moderate levels of activity had 58% and 53% lower mortality risks than those who engaged in minimal or no activity (Wannamethee SG, Shaper AG, Walker M. Physical activity and mortality in older men with diagnosed coronary heart disease. Circulation. 2000;102:1358-1363.)

Take home message: Spend time with your doctor discussing and quantifying your risks for heart disease. In addition, your doctor should address all of your risk factors for heart disease in a systematic manner by devising comprehensive preventive plans of action that should be regularly monitored and updated to address the major modifiable lifestyle factors. Remember that the focus of preventive medicine specialists is to spend their time on these important risk factors and helping you make changes to your lifestyle by engaging you in a long-term plan. The plan takes into account your environment, health behaviours and medical history so that the management is holistic.

Burden of Heart Disease in Today's Society

Burden of Disease (Coronary Heart Disease, Acute Coronary Syndrome and Angina Pectoris)

Prevalence:

On the basis of data from NHANES 2003 to 2006, an estimated 17,600,000 American adults age 20 and older have coronary heart disease (CHD). Total CHD prevalence is 7.9 percent in U.S. adults age 20 and older (9.1 percent for men and 7.0 percent for women).

Among U.S. adults age 20 and older, the overall prevalence of myocardial infarction (MI, or heart attack) is 3.6 percent (4.7 percent for men and 2.6 percent for women).

Incidence:

This year an estimated 785,000 Americans will have a new coronary attack and about 470,000 will have a recurrent attack. It is estimated that an additional 195,000 silent heart attacks occur each year.

The estimated annual incidence of heart attack (myocardial infarction,

MI) is 610,000 new attacks and 325,000 recurrent attacks annually.

The average age of a person having a first heart attack is 64.5 for men and 70.3 for women.

Based on the NHLBI’s Framingham Heart Study (FHS)…

– CHD makes up more than half of all cardiovascular events in men and women under age 75.

Mortality:

CHD caused about one of every six deaths in the United States in 2006. It is the largest major killer of American males and females.

Final 2006 CHD mortality was 425,425 (224,510 males, 200,915 females). CHD any mention mortality in 2006 was 587,000

Final 2006 myocardial infarction (MI) mortality was 141,462 (76,089 males, 65,373 females).

Myocardial infarction mortality in 2006 was 181,000.

About every 25 seconds, an American will suffer a coronary event, and about every minute someone will die from one.

About every 34 seconds, an American will suffer a heart attack.

In half of the cardiovascular disease deaths that occur every year, the first sign that anything is wrong are sudden cardiac arrest and death. 


Take home message: Heart Disease is the number one cause of death in today's society. In addition, it is a major cause of poor quality of life and has a huge impact on health-care associated costs. It is more than 80% preventable and hence can be mostly avoided by focusing on ways to prevent from developing it as mentioned previously.

The Ideal Cardiovascular Disease Risk Factor Profile: Your Key to Living a Long, Healthy Life

What evidence exists for the high potential preventability of cardiovascular diseases?

Several recent studies demonstrate that individuals who maintain a profile of ideal cardiovascular risk factor levels from young adulthood into middle age essentially escape their remaining lifetime risk for major CVD events. Indeed, both CVD and non-CVD mortality rates are reduced, thereby resulting in an additional 10 years’ longevity (Capewell, Simon and Lloyd-Jones, Donald M. Optimal Cardiovascular Prevention Strategies for the 21st Century JAMA, November 10, 2010—Vol 304, No. 18.2057-8).

Capewell et al. recently demonstrated that if the majority of the US population reached middle age with this ideal phenotype, more than 90% of the coronary heart disease deaths otherwise expected in 2010 might be prevented.

However, barely 5% of the US population now maintains this ideal profile into middle age.

For the first time, The American Heart Association (AHA) has defined the “ideal cardiovascular risk factor profile”, identifying the following seven health factors and lifestyle behaviors that support heart health termed Life’s Simple 7:

• Total cholesterol <200 mg/dL (untreated)
• BP <120/<80 mm Hg (untreated)
• Fasting blood glucose <100 mg/dL (untreated)
• Body mass index < 25 kg/m2
• Abstinence from smoking
• Physical activity at goal for adults > 20 y of age: 150 min/wk moderate intensity or 75 min/wk vigorous intensity, or combination
• Four to five of the key components of a healthy diet consistent with current American Heart Association guideline recommendations. For example, a Healthy (DASH-like) diet

DASH diet or Dietary Approaches to Stop Hypertension is a diet based on an eating plan rich in fruits and vegetables, and low-fat or non-fat dairy, with whole grains. It is a low salt, high fiber, low to moderate fat diet, and is rich in potassium, calcium, and magnesium. Many other diets have the same basic principles as this diet including the Mediterranean, South Beach and Zone diets.

The AHA created the definition as part of its effort to achieve its new national goal : By 2020, improve the cardiovascular health of all Americans by 20 percent while reducing deaths from cardiovascular diseases and stroke by 20 percent. The novel focus of the new goal will be preventing heart disease and stroke, most notably by helping people identify and adopt healthier lifestyle choices. This will be the first time the AHA has adopted better health as a principal goal.

In a recent survey of adult Americans, the AHA found that 39 percent said they thought they had ideal heart health; however, 54 percent of those (and 70 percent of all respondents) said a health professional had told them they had a risk factor for heart disease and/or needed to make a lifestyle change to improve their heart health. These findings indicate most people don't associate important risk factors, such as poor diet and physical inactivity, with cardiovascular disease. The Heart Strategies Concentrating on Risk Evaluation (Heart SCORE) Study found that less than 10% of participants met greater than or equal to five components of ideal cardiovascular death in all subgroups (by age, race, sex and income level) (Bambs, Claudia et al. Low Prevalence of "Ideal Cardiovascular Health" in a Community-Based Population. Circulation. 2011;123:850-857).

To help people improve their heart health, the AHA developed a new online resource – My Life Check. The short assessment easily identifies the seven goals for ideal health and notes where a person is on the spectrum, while additional tools and information offer specific action steps to improve the measurements and track personal progress toward better health.

Take home message: Begin talking to your doctor about achieving your ideal cardiovascular profile as soon as possible. This involves assessing your current risk factors for cardiovascular disease and putting in place a prevention plan that addresses the major modfiable lifestyle factors (smoking, diet, exercise and alcohol consumption among others). This plan should be constantly monitored and updated. Due to their specialty training, preventive medicine specialists take into account the environmental and biological factors that provide context to health behaviors so that prevention plans are holisitic in nature.

Burden of Cardiovascular (CVD) Diseases (Heart Disease, High Blood Pressure, Peripheral Arterial Disease, Stroke and Congestive Heart Failure)

Given that CVD is the number one leading cause of death and highly preventable (estimates approx. 80% preventable) as mentioned in previous posts, it would be reasonable to start looking at how to prevent this cluster of diseases first.

CVD Burden of Disease

CVD Prevalence (An estimate of the total number of cases of a disease existing in a population during a specified period. Prevalence is sometimes expressed as a percentage of population):

An estimated 81,100,000 American adults (more than one in three) have one or more types of cardiovascular disease (CVD). Of these, 38,100,000 are estimated to be age 60 or older. Total CVD includes diseases in the bullet points below except for congenital CVD. Due to overlap, it is not possible to add these conditions to arrive at a total.

• High blood pressure (HBP) — 74,500,000. (Defined as systolic pressure 140 mm Hg or greater and/or diastolic pressure 90 mm Hg or greater, taking antihypertensive medication or being told at least twice by a physician or other health professional that you have HBP.)

• Coronary heart disease (CHD) — 17,600,000.

– Myocardial infarction (MI, or heart attack) — 8,500,000.

– Angina pectoris (AP, or chest pain) — 10,200,000.

• Heart failure (HF) —5,800,000.

• Stroke — 6,400,000.

CVD Incidence (An estimate of the number of new cases of a disease that develop in a population in a one-year period):

Based on the National Heart, Lung and Blood Institute (NHLBI’s) Framingham Heart Study (FHS) original and offspring cohort (1980–2003):

The average annual rates of first major cardiovascular events rise from three per 1,000 men at ages 35–44 to 74 per 1,000 at ages 85–94. For women, comparable rates occur 10 years later in life. The gap narrows with advancing age.

– Before age 75, a higher proportion of CVD events due to CHD occur in men than in women, and a higher proportion of events due to stroke occur in women than in men.

• Data from the FHS indicate that the lifetime risk for CVD is two in three for men and more than one in two for women at age 40.

CVD Mortality:

Final mortality data show that CVD as the underlying cause of death (including congenital cardiovascular defects) accounted for 34.3 percent (831,272) of all 2,426,264 deaths in 2006,or one of every 2.9 deaths in the United States. CVD any mention

deaths (1,347,000 deaths in 2006) accounted for about 56 percent of all deaths in 2006.

In every year since 1900, except 1918, CVD accounted for more deaths than any other major cause of death in the United States.

• Nearly 2,300 Americans die of CVD each day, an average of one death every 38 seconds. CVD claims more lives each year as cancer, chronic lower respiratory diseases and accidents combined.

• The 2006 overall death rate from CVD was 262.5. The rates were 306.6 for white males and 422.8 for black males; 215.5 for white females and 298.2 for black females. From 1996–2006, death rates from CVD declined 29.2 percent. In the same 10-year period, actual CVD deaths declined 12.9 percent. (Appropriate comparability ratios were applied.)

CVD Costs:

The total direct and indirect cost of cardiovascular diseases and stroke in the United States for 2010 is estimated at $503.2 billion. This figure includes health expenditures (direct costs, which include the cost of physicians and other professionals, hospital and

nursing home services, medications, home health care and other medical durables) and lost productivity resulting from morbidity and mortality (indirect costs).

By comparison, in 2008 the estimated cost of all cancer and benign neoplasms was $228 billion ($93 billion in direct costs, $19 billion in morbidity indirect costs and $116 billion in mortality indirect costs).

Take home message: Cardiovascular diseases including heart disease, high blood pressure, stroke, peripheral arterial disease and congestive heart failure contribute to significant and important burden of disease. They are mostly preventable and therefore can be avoided by taking a preventive medicine approach to them.

Conditions and Diseases That Can Be Prevented And Treated With Lifestyle and Preventive Medicine

This post will begin a series of posts focusing on specific conditions that can be modified with the use of lifestyle and preventive type interventions that focus on the modifiable risk factors. At this point, I will enumerate all conditions for which there is evidence of impact through modification of lifestyle related risk factors. I will then go on to talk in depth about the most important diseases affecting our society – the so called “killer diseases” : heart disease, cancer, stroke, chronic obstructive pulmonary disease and diabetes

A. Obesity

B. Hypertension

C. Dyslipidemia

D. Impaired Glucose Tolerance/Metabolic Syndrome

E. Type 2 Diabetes

F. Cardiovascular Disease

G. Stroke

H. Heart Failure

I. Peripheral Artery Disease

J. Chronic Obstructive Pulmonary Disease

K. Osteoarthritis

L. Rheumatoid arthritis

M. Cancer – All

N. Breast Cancer

O. Osteoporosis

P. Depression

Q. Fibromyalgia

R. Chronic Fatigue Syndrome

S. Type 1 diabetes

T. Non-alcoholic fatty liver disease

U. Multiple Sclerosis

V. Parkinson’s

W. Cognitive Impairment/Dementia

X. Chronic Low Back Pain


Take home message: Preventive and lifestyle medicine approaches can be applied to a variety of diseases and conditions in order to improve their respective health outcomes. Most of the modifiable lifestyle risk factors overlap with each other and therefore tend to affect a multitude of conditions so the good news is that by focusing on this set of modifiable risk factors (smoking, diet, exercise, sleep, stress), we can prevent and treat a myriad diseases. Talking to your doctor about these risk factors that you can change with a comprehensive approach to prevention will tend to prevent the development of most of these diseases.

Barriers to the Adoption, Integration, and Delivery of Risk Assessments and Clinical Preventive Services

Most of the recommendations regarding clinical prevention come from an established and credible organization: The U.S. Preventive Services Task Force (USPSTF).


For example, the USPSTF recommends that clinicians screen all adult patients for obesity, tobacco use and alcohol use, and offer cessation interventions for smokers, and intensive counselling and behavioral interventions to promote sustained weight loss for obese, reduced alcohol consumption in excessive users, and diet changes for all who have hyperlipidemia or other known risk factors for cardiovascular and diet-related chronic disease. For an interactive version of what clinical preventive services you need, check the widget at the bottom right hand side of the blog – the electronic preventive services selector: just enter your age, gender, smoking status and sexual activity to see what services you need.


The USPSTF first convened by the U.S. Public Health Service in 1984, and since 1998 sponsored by the Agency for Healthcare Research and Quality (AHRQ), is the leading independent panel of private-sector experts in prevention and primary care. The USPSTF conducts rigorous, impartial assessments of the scientific evidence for the effectiveness of a broad range of clinical preventive services, including screening, counseling, and preventive medications. Its recommendations are considered the "gold standard" for clinical preventive services.


The mission of the USPSTF is to evaluate the benefits of individual services based on age, gender, and risk factors for disease; make recommendations about which preventive services should be incorporated routinely into primary medical care and for which populations; and identify a research agenda for clinical preventive care.


More recently, the Affordable Care Act adopted the recommendations of the USPSTF to legislate the coverage and provision of those recommended clinical preventive services by insurance plans across the US (including private and public –CMS included). This constitutes an important step towards the right direction as by law, CMS could only pay for "services and treatment for illness and malformation that are reasonable and necessary," and therefore prevention has always been ignored due to the manner in which the legislation was initially drafted. However, this is only a start and does not address the current health care delivery model that emphasizes disease management over prevention and lifestyle modifications.


The USPSTF also identified several barriers to the Adoption, Integration, and Delivery of Clinical Preventive Services which include the following:


1.Time constraints - Doctors face significant time constraints which may impede the delivery of the USPSTF recommendations. In fact, Yarnall (2003) estimated that it would take approximately 7.8 hours per day for a primary care physician to deliver all of the preventive services recommended by the USPSTF (screening, counseling, chemoprophylaxis, and immunization)(Yarnall KS, Pollak KI, Ostbye T, Krause KM, Michener JL. Primary care: Is there enough time for prevention? Am J Public Health. 2003;93:635-641.) This would be in addition to the 3.5 hours per day needed to deliver (tertiary) prevention associated with evidence-based chronic disease management -- assuming that all patients had well-controlled conditions (Ostbye T, Yarnall KS, Krause KM, Pollak KI, Gradison M, Michener JL. Is there time for management of patients with chronic diseases in primary care? Ann Fam Med. 2005;3:209-214.) 


2. Patient resistance – doctors usually state that “patients typically have their own agendas and priorities when they enter the exam room (which usually focus on symptom management), and it is difficult to turn the discussion to preventive health.” The issue here is not patients but rather the way in which healthcare is delivered. Your doctor should be using shared-decision making processes including health education and motivational interviewing within your own unique environmental context to discuss issues with you and empower you to make the right health choices.


3. Staff availability - Limited staff availability to complete the recommended clinical preventive services is a barrier in some health plans. There are not enough staff members to deliver all of the recommendations and many staff do not feel adequately trained on prevention.


4. Delivery of Counseling Recommendations. – counseling recommendations are more difficult to adopt and integrate than screening recommendations.


5. Barriers to Integration of Certain Types of USPSTF Recommendations - certain types of recommendations are easier to adopt and integrate than others.


6. Availability of Clinical Preventive Services in the System – some screening tests may not be available or there are waiting lists; or some staff do not feel trained to deliver behavioral counseling.


7. Geographic Barriers to Care 


8. Information Technology Barriers


9. Process Barriers – sometimes USPSTF recommendations are not aligned with other national health organizations’ recommendations.


10. Lack of local control


11. Barriers Related to Delivery of Recommendations in Clinical Practice – as mentioned in earlier posts, some physicians are not adequately trained about the delivery of certain preventive services (such as tobacco cessation, exercise and diet counseling), while others are not trained to assess health risk estimates properly. In addition, due to the changing nature of prevention guidelines, some might not feel they are up to date on the new recommended services.


Take home message: Due to a variety of factors pointed out above, the traditional medical practice is not able or equipped to deliver adequate services in preventive medicine including but not limited to health risk assessments, screenings and behavioural counselling. Many of these barriers can be overcome by focusing on a new model of clinical practice: a clinical preventive medicine practice that focuses entirely on disease prevention and health enhancement within each patient’s environmental context, a model that fits with the training and expertise of preventive medicine specialists.

How to Approach Health Risk Factor Assessment

There are different ways to approach risk factor assessment, but all of them should be taken together as they are complementary (adapted from Duke Personalized Medicine).

Disease Risk Assessments

Disease risk assessments use an individual’s personal, genetic, and environmental information to determine a quantitative or qualitative value of risk for developing specific diseases such as heart disease, cancer and osteoporosis. The tools calculate a personalized risk assessment "score" based on individual risk factors such as diet, exercise, smoking, alcohol consumption, family history, DNA, and biomarkers (blood tests, functional tests, or imaging tests that reflect normal physiologic or pathologic processes—such as blood sugar and blood pressure levels).

These risk assessment scores are the end product of research studies looking at the contribution of individual risk factors for each disease state.

For example, the Framingham Study identified several risk factors for the development of heart disease. It did this by collecting data on a large number of individuals living in Framingham, Massachusetts over a period of decades. At the end, researchers were able to statistically compare information from those who had heart attacks to those who did not, to identify which items were important risk factors for developing a heart attack.
These numbers allow both the patient and the physician to objectively determine where a patient’s current health status is compared to the general population and to their personal goal.
Changes in risk assessment scores over time can show the positive and negative impact from modifiable behaviors. In our example above, if a patient lowered his/her cholesterol through diet and exercise, the change in the Framingham score would provide objective feedback on how behavior has improved their health risk.

Health Assessments

In addition to these disease risk assessments, health assessments exist whereby health assessments are designed not to calculate risk for a specific disease, but to assess markers of the patient’s well-being--such as quality of life, functional status (ability to perform normal activities), satisfaction with health status, health-related goals, and intention to change health-related behaviors.

Combining these patient-centered measures with other traditional measures of health helps providers and patients to better communicate with each other, and gives providers the information they need to help motivate patients to change unhealthy behaviors.

Health Risk Assessments

Health Risk Assessments combine features of both disease risk assessments and health assessments in the form of questionnaires. A comprehensive assessment should include questions that address a fundamental set of risk factors: health behaviors (tobacco use, physical activity, dietary intake, sexual practices, alcohol and other drug use, injury prevention, exposure to ultraviolet light, dental hygiene); mental health and functional status; risk factors from medications, past medical and family history; occupational and environmental exposures; travel history; and the status of recommended screening tests, immunizations, and chemoprophylaxis.

The answers to your questions should then direct your doctor to give you absolute and relative risk estimates for various diseases (a risk factor profile) and a plan to modify those health behaviors that can be changed to modify the existing risk factor profiles.

Family health history (FHH)

Family health history (FHH) is a unique disease risk assessment tool based on information about health conditions that affect members of your family.

Within families, blood relatives share similar environments, lifestyles, and genetic backgrounds. As a result, FHH reflects the complex combination of all these factors on an individual's risk for developing health conditions.

To encourage more people to take advantage of this powerful tool, the Department of Health & Human Services has launched a Family History Initiative and the U.S. Surgeon General has declared that Thanksgiving Day also be known as National Family History Day. The free, online tool, My Family Health Portrait, was created to help people collect and store their family information. In addition, the Centers for Disease Control (CDC) has created a Family History topic page with multiple links to information about family history with resources for the public and health professionals.

Take home message: It is important for you to ask your doctor to conduct these various types of risk and health assessments at the initial “new patient” visit and to continually update them as risk factors and your health change. However, few doctors do these assessments due to a lack of training, knowledge, time or reimbursement incentives. Preventive medicine specialists are specifically trained to conduct these assessments and help you modify health behaviors within your own environmental context to decrease your chances of developing disease and enhance your health.

Towards a new model of patient-doctor interaction

In the last few posts, I have talked about the importance of adopting a risk-based approach to your own health and focusing on risk factors that can lead to the development of the “killer diseases”. I have also mentioned that this approach is the basis of clinical preventive medicine and that it is crucial to the concept of taking care of your own health before the development of disease.

In this post, I would like to spend some time of why the current doctor-patient model does not allow for this focus on prevention to happen naturally. In addition, I would like to propose a new model: one that is based on shared-decision making with the patient and a renewed focus on prevention.

We should all expect that our own doctors address the importance of these risk factors but this is not the case. For example, studies have shown that obese patients are advised to lose weight only 36% of the time during regular examinations, a proportion that improves only slightly to 52% if a patient already has obesity-related complications. Furthermore, only 28% of smokers reported that health care professionals had offered them assistance to quit smoking in the past year. (Lianov, Liana and Johnsson, Mark. Physician Competencies for Prescribing Lifestyle Medicine. JAMA July 10, 2010, 304(2).202-203.).

Moreover, approximately only 34% to 50% of adult patients remember receiving exercise counseling, and physicians miss many opportunities for physical activity counseling.

In 2001, only 8.2% of total outpatient visits included counseling or education related to exercise. (Jacobson et al. Physical Activity Counseling in the Adult Primary Care Setting Position Statement of the American College of Preventive Medicine. Am J Prev Med 2005;29(2). P.158-162.)

These types of studies show that doctors should be accountable for and be responsible for the inability to effectuate important health behavior changes in their patients. It is paramount and a crucial duty for doctors to help their patients adopt healthier behaviors, because patients cannot entirely effectuate these changes on their own.

Yet, physicians continue to ignore this important function, why?

Well for, one doctors have cited inadequate confidence and lack of knowledge and skill as major barriers to counseling patients about lifestyle interventions. Among the 620 respondents in a survey of family physicians, only 49% felt competent prescribing weight loss programs for obese patients (Lianov, Liana and Johnsson, Mark. Physician Competencies for Prescribing Lifestyle Medicine. JAMA July 10, 2010, 304(2).202-203.). In addition, several studies have shown that physicians in training do not adequately get trained these lifestyle-level interventions to prevent and treat chronic medical diseases (Sisson, S and Dalal, D. Internal medicine residency training in topics on ambulatory care: a status report. Am J Med. 2011; 124: 86-90).

 

Another reason for the lack of focus on risk factor assessment and prevention is the perverse reimbursement mechanism by insurance companies whereby doctors are paid to treat existing disease rather than focus on prevention. In fact, only recently did the Affordable Care Act (ACA) legislate the mandate to cover clinical prevention. Even though this represents a good start, ACA falls short of providing full comprehensive coverage on prevention.

Take home message: Patients are therefore left to fend for themselves to figure their own risk for diseases and how to best prevent them, unless you have a qualified doctor, such as a preventive medicine specialist, who can help with risk factor assessment and putting in place robust prevention plans. Preventive medicine specialists are able to help you complete risk assessment profiles and focus on behavioural counseling (smoking cessation, nutrition counseling and exercise prescriptions), recommendations for screening exams and preventive medications, while at the same time taking a holistic preventive approach to your health care needs.

The Importance of Discussing Risk with your Doctor

A critical concept to understand before talking to your own doctor about your chances of developing diseases based on your own risk factors is the notion of risk.

Risk is defined as the probability or chances that a chosen course of action leads to an adverse event. Implicit in this term is the concept that risk is not an all or nothing concept, but rather a probabilistic concept. Most doctors talk about having a disease or not – that is, a categorical concept which is antiquated and not useful for patients. In contrast, risk factors are dimensional because risk is a continuum. The argument follows that when risk data are available, your doctor should discuss disease not as a category but as a probability. Rather than a disease label compelling treatment (eg, I have cancer, remove it), a risk estimate allows patients and doctors to practice clinical-actuarial correlation (eg, my chance of cancer death is too low to justify surgery).

Your health care provider should also be transparent and take the time to explain you the different type of risk estimates that they are providing which may include the following:


1. Absolute risk - your risk of a heart attack in 10 years is x%
2. Relative risk - your risk of having the disease is 3 times higher than an average person of the same       age, gender and race.
3. Modifiable risk - if you stop smoking, your risk will decrease by x%

Why is risk such an important theme to discuss with your doctor then? Well, for one, I hope that I have made the argument that because it is actually risk factors and their prevention that leads to your good health and living a disease-free life. More importantly, it is important to discuss risk because most of us do not actually know or have a distorted concept of what our own risk of developing disease is. In addition, accurate perception of a patient’s risk by both the patient and the doctors is important as this is one of the components that determine health-related behavior.

Doctors tend underestimate the absolute heart disease risk of their patients. Patients show optimistic bias when considering their own risk and consistently underestimate it (Webster Ruth and Heeley, Emma. Perceptions of Risk: Understanding Cardiovascular Disease. Risk Management and Healthcare Policy 2010:3 49–60).

Doctors should take responsibility for the accurate assessment and effective communication of risk in their patients in order to improve patient uptake of lifestyle choices and preventive medications.

Take home message: Risk is an important concept to discuss with your doctor in order to be able to take control of your own health, but yet few people do so. The reasons for this are numerous and will be the topic of discussion in future posts.

Prevalence of Select Risk Factors

Now that I have explained how these risk factors are the key factors in addressing your own chances of developing diseases, I would like to take some time to talk about some of the statistics regarding the prevalence of our own risk factors (this term refers to the total number of people who have a certain disease divided by the total population and is often expressed as a percentage).

Prevalence of select modifiable risk factors (Source: Behavioral Risk Factor Surveillance System):

•       1 in 5 people smoke and 2/5 exposed to 2nd hand smoke

•       1 in 10 eat the recommended guidelines for fruits and vegetables

•       3/4 people do not get enough physical activity

•       1/3 adults (ages 30-64) get less than 6 hours of sleep/night

More surprising,

• only 1 in 33 (3%) had healthy levels of all 4 lifestyle behaviors (non smoking, healthy weight, 5 fruits and vegetables per day, and regular physical activity).

Prevalence of select intermediate risk factors (Source: American Heart Association):

• Obesity/overweight – 2/3
• Abdominal obesity – 1/2
• High blood pressure – 1/3
• High Bad Cholesterol – 1/3
• Low Good cholesterol – 1/5

Prevalence of select diseases:

Diabetes – 11.3% of adults 20 and over with an additional 35% having pre-diabetes (Source: CDC)

Cardiovascular disease (includes all forms of heart disease and stroke)  –  37% (Source: American Heart Association) 

One would think that for those who already suffer from an illness, it would be more important to change and adopt healthier behaviors, but statistics do not reveal this. In fact, only 11% of patients with diabetes follow accepted dietary recommendations for saturated fat intake, and 18% of patients with heart disease continue to smoke, roughly the same as the general population's smoking rate (Lianov, Liana and Johnsson, Mark. Physician Competencies for Prescribing Lifestyle Medicine. JAMA July 10, 2010, 304(2).202-203.)

Take home message: Few people adhere to health behaviors despite of the overwhelming evidence that these risk factors lead to and cause the “killer diseases” even if we already have one of these diseases. However, even if you are in control of these lifestyle-related behaviours and have the desire to change, it is often difficult. Where can you get help? A natural place would be the doctor’s visit but as mentioned before unfortunately many doctors do not practice prevention due to a variety of reasons that I will get to in future posts. However, Preventive Medicine trained doctors are specialized in providing this type of service.

Modifiable Risk Factors

As mentioned in my previous post, we should all be focusing our attention on the actual risk factors that cause chronic diseases in order to prevent from developing them in the first place. I presented the seminal study Actual Causes of Death in the United States, 2000 that highlights the true root causes of these “killer diseases”. A newer 2009 study entitled The Preventable Causes of Death in the United States: Comparative Risk Assessment of Dietary, Lifestyle, and Metabolic Risk Factors (Danaei G, Ding EL, Mozaffarian D, Taylor B, Rehm J, et al. (2009) The Preventable Causes of Death in the United States: Comparative Risk Assessment of Dietary, Lifestyle, and Metabolic Risk Factors. PLoS Med 6(4)) presents similar findings but includes a greater variety of risk factors.

The aim of this study was to estimate the mortality (another term for death) effects of the following 12 modifiable dietary, lifestyle, and metabolic risk factors in the United States (US) using consistent and comparable methods: high blood glucose, low-density lipoprotein (LDL) cholesterol, and blood pressure; overweight-obesity; high dietary trans fatty acids and salt; low dietary polyunsaturated fatty acids, omega-3 fatty acids (seafood), and fruits and vegetables; physical inactivity; alcohol use; and tobacco smoking.

The results showed that in 2005, tobacco smoking and high blood pressure were responsible for an estimated 467,000 and 395,000 deaths, accounting for about one in five or six deaths in US adults. Overweight-obesity (216,000) and physical inactivity (191,000) were each responsible for nearly 1 in 10 deaths.

High dietary salt (102,000), low dietary omega-3 fatty acids (84,000), and high dietary trans fatty acids (82,000) were the dietary risks with the largest mortality effects. Alcohol use caused an additional 90,000 deaths.

Take home message: Smoking and high blood pressure, which both have effective interventions, are responsible for the largest number of deaths in the US. Other dietary, lifestyle, and metabolic risk factors for chronic diseases also cause a substantial number of deaths in the US.

I also want to stress that these modifiable risk factors are not only important in the development of chronic diseases but also in the development and progression of more acute diseases such as the common cold. For example, exercise has been show to reduce the chances of developing and the symptoms associated with the common cold.

I hope that I have made a strong case for addressing our own modifiable risk factors (tobacco smoking, diet, exercise and alcohol use) and that we ask these questions to our own doctors so that we focus on what really matters: preventing the development of diseases rather than focusing on managing the symptoms of diseases once they have developed.