The Top Ten Preventive Services, Ranked by Bang for the Buck

doctor appleWith all the controversy about the utility of mammography, optimal Pap smear intervals, and risks of prostate cancer screening, you have to ask yourself – what are the most beneficial and cost effective preventive services we should be focusing on?

Here are the top 10 preventive services. These items were chosen by the National Commission on Prevention Priorities, and highlight those preventive services including immunizations, screenings, preventive medications, and counseling that give “the most bang for the buck.”  For an in depth discussion of methods and results, read Am J Prev Med 2006;31(1):52–61

{The Top Ten}:

Discuss Daily Aspirin Use
This counseling does not mean everyone should take aspirin to prevent heart attack and stroke, but rather that individuals at moderate to high risk should weigh with their doctors the risks of bleeding and ulcers against the benefits of reducing cardiovascular disease. Heart attacks, strokes, and peripheral arterial disease accounts for over 900,000 deaths in the United States each year. According to Up To Date, net benefits of aspirin have been proven in secondary prevention for those who’ve already suffered a heart attack, occlusive stroke, TIA, angina, or coronary bypass surgery. Acute ischemic syndromes such as acute MI, unstable angina, and acute occlusive stroke also benefit.

Aspirin use for primary prevention of a first cardiovascular disease event is the most controversial, with recent trends favoring only using aspirin for those found to be at moderate to high risk. The National Commission estimates that “Physicians advising all high-risk adults to consider taking aspirin would save 80,000 lives annually and result in a net medical cost savings of $70 per person advised.”

The discussion with a doctor if aspirin is appropriate for you is very tricky, and is currently undergoing some changes based on new evidence, but the discussion may save your life, either way.

Childhood Immunization
The Advisory Committee recommends vaccinations against hepatitis B, diphtheria, tetanus, pertussis (whooping cough), Haemophilus influenzae type b (Hib), polio, measles, mumps, rubella, varicella (chicken pox), pneumonia, and influenza for average risk children. This series is cost- saving and highly effective, and has made childhood deaths and suffering from the above diseases rare. Immunizing children also protects the health of the community, including those who are too young to be vaccinated or cannot be vaccinated for medical reasons, as circulating epidemics cannot easily take hold in an immune population.

Smoking Cessation Advice and Help to Quit
The harms of smoking are self-evident. It is estimated that smoking results in $100 billion annually in medical costs. Smoking also creates collateral damage to those non-smokers passively exposed. Clinicians should screen all adults to determine if they smoke or use other tobacco products, provide brief counseling, and offer patients nicotine replacement therapies and referrals to help them quit. What is most frustrating is that nicotine, as addictive as heroin and cocaine, is tolerated at all by our society – and that many health insurance companies will not pay for smoking cessation counseling or meds to help patients quit.

Screening for Alcohol Misuse and Brief Counseling
15% of adults report excessive drinking binges, more commonly in younger adults but still quite prevalent in older. Harmful alcohol use is associated with violence, accidents, injuries, deaths and disability, social disruption, and health problems. Many doctors consider more than 7 drinks/week or 3 drinks/occasion risky for women, and 14 drinks/week or 4 drinks/occasion hazardous for men, but in the context of certain activities like driving no amount is safe. Many people are unaware that their alcohol use is excessive and will change their habits when a doctor points it out.

Colorectal Cancer Screening
Colonoscopy remains the gold standard for early detection and prevention of colon cancer, although other options include fecal occult blood testing and sigmoidoscopy. Colon cancer is the 3rd highest incident cancer in the U.S. with 160,000 new cases in 2008, and 55,000 deaths. 19,000 deaths could be prevented each year if people over age 50 were periodically screened as recommended. It is estimated that only 1/3 of adults are up to date with screening. The risks of colon perforation are quite small but should be discussed with the doctor.

Hypertension Screening
It recommended that blood pressure be measured routinely in all adults over 18 and that anti-hypertension medications be taken to prevent the incidence of cardiovascular disease. 30% of American adults have hypertension, resulting in at least $100 billion in medical costs. Due to various factors only 1/3rd of hypertension cases are controlled. Many suitable generic medicines exist in this category. A low salt diet, weight loss, and exercise are also very effective means to lower blood pressure.

Influenza Immunization
The Advisory Committee on Immunization Practices recommends annual flu shots for those adults over 50 years of age, women who will be pregnant during the flu season, persons with certain chronic medical conditions, children 6 months to 18 years old, and several other important adult and pediatric groups you can review at the CDC. Influenza contributes to 35,000 deaths in the U.S. each year, many hospitalizations, absenteeism and presenteeism at work. The flu shot has been proven to protect against getting the flu to varying degrees based upon patient characteristics and each year’s serological match.

Vision Screening
Recommended especially for elderly persons using a Snellen acuity test (the one that hangs on the wall). Very cost effective, and vision correction can reduce hip fractures from falls, improve quality of life, reduce accidents, help with proper use of medication bottles, and increase activities such as exercise. Up to 25% of older people wear inappropriate visual correction.

Cervical Cancer Screening
While the starting age and interval between Pap smears is currently in debate again, screening for cervical cancer in women is certainly effective. It is largely responsible for the 50% decline in cervical cancer mortality over the past 30 years. Further long-term benefits remain to be studied for the HPV vaccination series, but this also looks quite promising for women.  The American College of Obstetrics and Gynecology released new guidelines just last month, but these are still quite new and your doctor may advise more frequent screenings.

Cholesterol Screening
The U.S. Preventive Services Task Force Recommends: “Screen routinely for lipid disorders among all men aged 35+ and all women aged 45+. Also screen men aged 20-35 and women aged 20-45 if they have other risk factors for coronary heart disease. Treat with lipid-lowering drugs to prevent the incidence of cardiovascular disease.”

The facts cited by the report are convincing:
~21% of adults age 35+ have high cholesterol. Of these, most will develop high cholesterol before age 55.
~One out of 4 adults who do not control their high cholesterol will have a cholesterol-attributable heart attack. One out of 3 will die of cholesterol-attributable coronary heart disease.
~Long-term use of therapies is necessary to achieve maximum benefits of screening

There you have it, the top ten preventive services for the U.S. population, ranked based upon an evidence-based analysis of costs and impacts of benefits and harms.

Other clinical preventive services that are valuable include pneumococcal vaccination, breast cancer screening for women (also recently controversial in terms of risks/benefits), chlamydia screening for sexually active women under age 25, discussing calcium supplementation, vision screening for preschool children, discussing folic acid supplementation for women of childbearing age, obesity screening in adults with high-intensity counseling about diet and exercise, depression screening, hearing screening in adults over 65, injury prevention counseling for parents of children 0-4 years of age, osteoporosis screening of women over 60-65, diabetes screening, diet counseling, and tetanus-diptheria boosters.  Interestingly, PSA testing did not make the list.  Most doctors still order this test annually in the absence of a better option for men, perhaps out of fear of missing prostate cancer and getting sued for it, regardless of the thorny question of whether early detection and treatment prolongs life. Until we have medical malpractice reform, perhaps in the form of specialized healthcare courts, doctors are still judged by lay juries and not scientific evidence when the inevitable bad things happen… but I digress.

You can review all the rankings by visiting the website directly. CPB is clinically preventable burden, or the disease, injury and premature death that would be prevented if the service were delivered to all people in the target population. CE is cost effectiveness, which is a standard measure for comparing services’ return on investment. The rankings are based on both CPB and CE. Services with the same total score tied in the rankings:
10 = highest impact, most cost effective among these evidence-based preventive services
2 = lowest impact, least cost effective among these evidence-based preventive services.

You will notice that full body CT scanning and taking twenty different vitamins did not make the list. Hopefully these rankings put things in perspective for policy makers, and serve as a starting point for future discussions with your doctor.  Apples are good, too, and I recommend the Honey Crisp variety.