Oct 08 2008

Preventative Hype

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Comments: 8

A recent editorial in the New York Times by Dr. H Gilbert Welch discusses the role preventative health care, separating out the complex reality from the simple sound bite. He points out that both presidential candidates have made statements suggesting that increasing prevention can save health care dollars, while the evidence is not clear.

Dr. Welch gets the issue essentially correct. First, we must consider that there are different types of prevention. The first type, and perhaps what most people think of as prevention, is living a healthy lifestyle, including eating a well-balanced diet, exercising regularly, and avoiding bad habits like smoking. This type of prevention is clearly a net positive – it doesn’t cost anything and people live longer. Although the net health effects are clearly positive, the net financial effects are more complex. If people are productive longer, and therefore the proportion of healthy working citizens to retired or unhealthy citizens is greater, then the financial benefits are clear. But if living healthy merely extends retirement then health costs are merely delayed by living healthy, but they will catch up with us eventually. I think most people will agree that living a longer healthier life is worth any extra cost of entitlements for the elderly.

The second type of preventative health care is screening in order to make early diagnosis. Dr. Welch correctly points out that screening programs are as likely to cause harm as they are good, even though at first this may seem counterintuitive. This is because screening tests are not perfect. They may have direct risks and may therefore cause as much harm as they prevent. They also have a false positive rate – which means that people may suffer the consequences of a false diagnosis. This could me further confirmatory tests that entail more risk, or even unecessary treatment.

What this means is that screening tests are not a no-brainer – more information is not always better. It is probably better never to know about a benign biological anomaly that would never cause you any problems in the first place. Screening tests need to be evidence-based, with their net effects thoughtfully measured and public health policy and the standard of care established accordingly.  This is already done. It is an ongoing process as our diagnostic technology and knowledge of diseases and treatments evolve.

I would separate out a third category of prevention – early treatment and ongoing management. This is, of course, linked to screening but is not the same thing. Early treatment could mean seeking proper care at the earliest symptoms (while screening seeks to find and treat problems before symptoms appear or for asymptomatic risk factors, like hypertension).

It is in this third category where I think the biggest gains are to be had, and this is something that changing the health care system (the system of delivery and payment, rather than the evidence-based practices) can have an impact.

The dilemma is that if the system includes a deductible or some barrier or disincentive to seek treatment, people will put off seeking medical attention and real health problems will progress until they are more difficult and more expensive to treat. People will also tend to use emergency services, rather than primary care. If, on the other hand, all such barriers are removed then people will overuse services, mostly for self-limiting problems. This overwhelms the system, causing delays in access, overworked doctors and nurses, and the quality of care decreases, offsetting the benefits of easy access. In a managed care system there are no barriers to seeking treatment, but gatekeepers limit access to tests and specialists. The promise of managed care was increased preventative treatment, but the reality turned out to be rationed care.

Therefore I do not think there is any easy solution, and just promising more preventative care is not enough. New institutions and ways of delivering care may need to be created in order to find a proper balance between allowing easy access for those who need it, while screening out those who don’t. Further, more attention needs to be paid to cost-benefit analysis. It frankly doesn’t matter if we have the best medical technology in the world if the system can’t afford it.

One component of such a system should be optimal preventative care – with the knowledge that this is not a panacea. Prevention needs to be evidence-based as much as treatment.

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