Monday, August 10, 2020

How do primary care physicians prioritize preventive services?

- Kenny Lin, MD, MPH

Although many clinical preventive services, including childhood immunizations, have unfortunately been deferred during the COVID-19 pandemic, it was difficult to address the lengthy list of screening tests, counseling, and preventive therapies with an "A" or "B" letter grade from the U.S. Preventive Services Task Force (USPSTF) even when most primary care visits were in person. In a previous AFP Community Blog post, I wrote about the National Commission on Preventive Priorities' (NCPP) ranking of preventive services based on population health impact and cost-effectiveness. The NCPP's highest-ranked services were the childhood immunization series; counseling and medications to assist smoking cessation in adults; and counseling to prevent initiation of tobacco use in children and adolescents. However, it isn't known how family physicians and other primary care clinicians actually prioritize the services we provide at health maintenance visits.

In a recent study published in JAMA Network Open, researchers from the Cleveland Clinic and Case Western University surveyed 137 internists and family physicians in their health system about 2 hypothetical adult patients who were each eligible for at least 11 preventive services. Based on the patient profiles and visit lengths (20 or 40 minutes), physicians were asked if they would find it necessary to prioritize preventive services, the factors they considered, and what their top 3 priorities were. The researchers compared physicians' stated priorities with a mathematical model that predicted what preventive services were most likely to improve life expectancy.

Unsurprisingly, physicians were more likely to need to prioritize services during a shorter visit, and they selected services that they thought would improve the patient's quality of life, help the patient live longer, and were strongly recommended by their professional organization or guidelines. Cost and patient adherence were less important in determining the services physicians discussed. Across both hypothetical patients, smoking cessation, hypertension control, glycemic control, and colorectal cancer screening were the most highly prioritized services. Only 35% of physicians included a lifestyle intervention (diet and exercise or weight loss) in their top 3 services, even though the mathematical model ranked both lifestyle interventions among the top 3 improving life expectancy for both patients.

As the researchers acknowledged, the intensive behavioral counseling interventions recommended by the USPSTF for adults with cardiovascular risk factors are not feasible in most primary care settings; lifestyle change presents substantial adherence challenges; and diet and exercise counseling are not generally included in quality of care metrics. However, brief evidence-based strategies to encourage health behavior change, as described in a 2018 FPM article, may be effective to prevent cardiovascular disease in individual patients. A recent post on FPM's Getting Paid Blog suggested three steps for family physicians to improve patients' utilization of preventive services during the pandemic.