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.
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