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Conclusions and Future Directions for Periodic Reporting on the Use of Selected Adult Clinical Preventive Services — United States

Ralph J. Coates, PhD1

Lydia Ogden, PhD2

Judith A. Monroe, MD3

James Buehler, MD1

Paula W. Yoon, ScD4

Janet L. Collins, PhD5

1Public Health Surveillance and Informatics Program Office, Office of Surveillance, Epidemiology, and Laboratory Services

2Office of the Director, Office of the Associate Director for Policy

3Office for State, Tribal, Local, and Territorial Support

4Epidemiology and Analysis Program Office, Office of Surveillance, Epidemiology, and Laboratory Services

5Office of the Director, Office of the Associate Director for Program

Corresponding author: Ralph J. Coates, PhD, Public Health Surveillance and Informatics Program Office, CDC, 1600 Clifton Rd, NE, Mailstop E-97, Atlanta, GA 30333. Telephone: 404-498-0080; Fax: 404-498-0595; E-mail: RCoates@cdc.gov.

The findings described in this supplement can help improve collaboration among public health and other stakeholders who influence population health, including employers, health plans, health professionals, and voluntary associations, to increase the use of a set of clinical preventive services that, with improved use, can substantially reduce morbidity and mortality in the U.S. adult population (1–19). This supplement highlighted that the use of the clinical preventive services in the U.S. adult population is not optimal and is quite variable, ranging from approximately 10% to 85%, depending on the particular service (Table). Use was particularly low for tobacco cessation, aspirin use to reduce risk of cardiovascular disease, and influenza vaccination; however, ample opportunity exists to improve use of all of these services. Among the specific populations least likely to have used the recommended services (210), persons with no insurance, no usual source of care, or no recent use of the health-care system (if included in the analysis) were the groups least likely to have used the services. Use among the uninsured was generally 10 to 30 percentage points below the general population averages, suggesting that improvements in insurance coverage are likely to increase use of these clinical preventive services. A randomized, controlled trial of an expansion of Medicaid coverage by Oregon in 2008 supports this hypothesis by demonstrating improved use of clinical services with increased health insurance coverage (20). A recent survey among the uninsured found a low level of awareness of the provisions of the Patient Protection and Affordable Care Act of 2010 as amended by the Healthcare and Education Reconciliation Act of 2010 (referred to collectively as the Affordable Care Act [ACA]) (21). Therefore, improving opportunities for coverage might be insufficient, and focused efforts by governmental health agencies and other stakeholders are likely to be needed to enroll uninsured persons in health plans. In addition, although use of the preventive services in insured populations was greater than among the uninsured, use among the insured was generally <75%, and often much less (210). Therefore, having health insurance coverage might not itself be sufficient to optimize use of clinical preventive services, and additional measures to improve use are likely to be necessary.

Opportunities Identified by Key Findings

The suboptimal use of adult clinical preventive services reported in this supplement can be improved and morbidity and mortality substantially reduced. Public health, other stakeholders, and communities can make use of the strategies identified in the reports to improve service use, including increasing health insurance coverage through effective implementation of the Affordable Care Act, participating in quality of care improvement initiatives, increasing the integrated use of electronic health information systems, implementing the National Prevention Strategy, better coordinating and integrating public health and clinical care, and increasing use of evidence-based community interventions to improve service use. For use of these services to actually increase and for the related improvements in the health of the U.S. adult population to be realized, key stakeholders and communities will need to take advantage of the opportunities and act to implement these strategies. Public health surveillance reports, such as this supplement, can play a key role in promoting accountability among stakeholders by monitoring and reporting on progress both in the use of clinical preventive services and in the implementation of strategies to improve service use.

The reports in this supplement identified numerous evidence-based, effective community interventions and quality-of-care improvement initiatives that can be implemented by stakeholders to increase use of clinical preventive services (210,19). Many of the community interventions have been found to improve service use among underserved populations (210,19). The specific interventions available vary somewhat depending on the service but commonly include reducing barriers to access to the service and integrating into health-care systems the ability to easily track service use and prompt clinicians or patients when the service is needed.

Most of the reports identified aspects of recent health-care reform initiatives that should facilitate increased use of these services (210). For example, when fully implemented, the Affordable Care Act is projected to extend health insurance coverage to approximately 93% of U.S. residents by 2016 (11,22). In 2009, 19.5% of the population (58.7 million persons) lacked health insurance for at least some part of the previous 12 months (23). In addition, the Affordable Care Act requires that certain clinical preventive services be provided without cost sharing by Medicare and newly qualified private health insurance plans and encourages the provision of selected services at no cost by Medicaid (11). A February 2012 analysis by the U.S. Department of Health and Human Services (HHS) reported that 54 million persons are receiving preventive services coverage without cost sharing as a result of the Affordable Care Act; 14.1 million of these are children aged ≤17 years, 20.4 million are women aged 18–64 years, and 19.5 million are men aged 18–64 years (24,25). In addition, HHS reported that 35 million Medicare beneficiaries are receiving free preventive services (24,25).

Health System Reforms at State and Local Levels

The Affordable Care Act includes provisions to improve disease prevention and health promotion, improve the quality of health care, and lower health-care costs (11,22). Implementation of those health system and public health provisions is largely the responsibility of states and communities, health insurers, and health-care providers, and choices made during implementation will directly affect use of clinical preventive services by those populations. Starting in 2014, Medicaid will expand to cover persons with incomes ≤133% of the federal poverty level (22). By 2016, an additional 16 million persons will be covered through Medicaid and the Children's Health Insurance Program (CHIP) (22). In addition, starting in 2014, the law creates state-based health insurance exchanges to make private health insurance available to small employers and to individual persons and families not eligible for Medicaid or CHIP (26,27). Within broad parameters, the law affords states considerable discretion in how they structure features of the plans, which can affect the delivery of clinical preventive services: cost sharing, eligibility for additional low-income subsidies, whether the exchange will include all qualified plans or only those with which the state contracts, governance, rating rules, adjusting premiums for risk, the range of benefit options, how to facilitate comparison shopping among plans, and public protections (27). Each of these decisions can directly or indirectly affect use of clinical preventive services and receipt of needed treatment.

Opportunities for states and communities to increase the use of clinical preventive services also are provided by national legislation supporting increased use of health information technology and electronic health records in hospitals and clinics (1,28). Electronic health information systems have the potential to improve the identification of individual persons and populations in need of services (e.g., persons who have not had a cholesterol check within the recommended interval or who have not received their annual influenza vaccine), provide reminders to both the health-care providers and patients about the need, and monitor and report on use of the services (1). State and local governments can play important roles in the implementation of such systems by providing leadership and governance, participating in the exchange of health information, and monitoring and reporting on adoption of health information systems to the public (28).

Public Health and Clinical Care

Interaction between clinical and community preventive services is recognized as one of four core strategies in the first National Prevention Strategy (11,29). The Affordable Care Act called for the development of the National Prevention Strategy in recognition of the essential role of prevention in improving the health of persons in the United States (11,29). Making meaningful health improvements through prevention will require action both within and beyond the health-care sector. The National Prevention Strategy highlights the important role of preventive services, including both clinical preventive services and community services discussed in this supplement, and the responsibility of communities to support these services. The public health sector can play a critical role in informing the public and key stakeholders about the benefits of clinical preventive services and in promoting evidence-based strategies such as those identified in this supplement. The National Prevention Strategy recognizes that patients receive both clinical and community services when they receive appropriate clinical preventive care that is supported by community-based resources such as tobacco quitlines, physical activity programs, and community programs to address barriers to health-care access. The combination of clinical and community services can optimize health through preventive health services. In addition, public health data on the use of preventive services, such as those highlighted in these reports, are critical for planning and monitoring community and health system interventions to increase the use of these services.

In this context, state, tribal, local, and territorial public health agencies have new opportunities to improve use of the clinical preventive services discussed in this supplement by improving the coordination and integration of agency services with those sponsored by state Medicaid agencies and those delivered by the health-care system. In the United States, the medical and public health fields have historically been in separate, although occasionally overlapping, realms. Realizing the potential for the Affordable Care Act to address U.S. health challenges of the 21st century, such as the aging population, increasing rates of chronic illness, and fragmented delivery of health care, will require the coordinated and deliberate redesign of the health care and public health systems.

Several steps might be considered by public health and other stakeholders to improve delivery of the clinical services identified in this supplement by better coordinating efforts and improving coordination of clinical care and public health. Health officials can share this report with their clinical community and convene meetings to discuss statewide and local strategies to support the optimal use of preventive services. They can work with employers and insurers to review health plan benefit language to improve coverage for all of the medical procedures required to implement a single clinical practice guideline and for appropriate populations to be covered (30,31). Health officials also can facilitate collaboration among hospital associations, medical staff leaders, professional trade associations, and residency program directors to improve access to preventive services. Medical practices that use electronic health records can assess individual practitioner or group practice performance on service delivery and work to improve office systems that increase rates of use. At the same time, public health officials can apply strategies to encourage members of the public to seek these services and help practitioners to understand the community services available to their patients to support health-promoting behaviors such as tobacco cessation. Claims data for state Medicaid and private insurance can be used locally to target attention to populations with the greatest service gaps. Public health professionals can work with leaders in business, voluntary associations, and faith-based organizations to use their leadership positions to increase awareness of the gap in services and encourage the use of clinical preventive services.

Improving Public Health Surveillance

Ideally, public health surveillance systems would have the capacity to track, in a timely, comprehensive, and accurate manner, the effects of numerous efforts that might influence use of clinical preventive services, including implementation of the Affordable Care Act and electronic health information systems, as well as actions by public health and other stakeholders. These systems would have the ability to characterize persons who are eligible for specific services and those who do or do not receive them, examine the effects of legislation and other interventions, and assess resulting health outcomes at both the individual and population levels. The ability of current resources and public health surveillance systems to examine such relationships is limited. However, surveillance reports such as those in this supplement can be helpful by highlighting underuse of the services, identifying trends that might be due, in part, to various interventions currently underway, and illuminating disparities. The reports in this supplement also highlight several gaps in the types of health surveillance information needed to guide efforts to increase use of important clinical preventive services. For example, as noted in the Rationale for this supplement, several preventive services of interest could not be addressed because of a lack of available information (1). Although all these reports present national data, most cannot provide data that are necessary to monitor progress at the state and local levels. This supplement challenges health and public health professionals to identify resources that can be used to provide information at the state and local levels.

Additional sources of health surveillance information might help address some of the gaps identified in these reports. Increasing use of electronic health information systems and electronic data exchange systems offers the possibility of collecting and reporting on use of clinical preventive services at the national, state, and local levels (1,28). State and local surveys, such as the Behavioral Risk Factor Surveillance System, might be able to capture more of the kind of information included in this supplement. Deidentified information from Medicare and Medicaid databases also might provide new opportunities for this type of surveillance (32). Additional sources of information for surveillance and an increased ability to link information from a various sources can help provide a more complete and integrated perspective on steps that stakeholders need to take to improve use of these services.

Future Reports on Clinical Preventive Services

Surveillance reports on the use of selected clinical preventive services by U.S. adults will be published periodically. Future reports might include additional indicators for clinical preventive services that are known to have important health benefits but were not included in this supplement for various reasons, primarily lack of adequate surveillance information (1). Such reports might include screening and counseling for alcohol consumption and for mental health, services that can benefit large segments of the adult population. Because this supplement does not address the important goal of improving use of clinical preventive services for adolescents and children, CDC is planning a surveillance report on use of those services and methods for improvement. As information becomes more available in public health surveillance systems, future reports might be useful for monitoring interventions implemented by public health and other stakeholders to improve service use.

Acknowledgments

This report is based, in part, on contributions by Kelly J. Henning, MD, Public Health Programs, Bloomberg Philanthropies, New York, New York.

References

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TABLE. Percentage of adults who are receiving selected clinical preventive services — United States

Topic/Indicator (years received)

% receiving service

Aspirin and other antiplatelet therapy (2005–2008)

Adults aged ≥18 years with a history of ischemic vascular disease who are prescribed aspirin or antiplatelet therapy to prevent recurrent CVD

46.9*

Men aged 45–79 years and women aged 55–79 years without ischemic vascular disease who are prescribed aspirin when the potential benefit of a reduction in myocardial infarction or stroke, respectively, outweighs the potential harm attributable to an increase in gastrointestinal hemorrhage

17.1*

Hypertension management (2005–2008)

Adults aged ≥18 years with hypertension whose blood pressure is under control

43.6

Lipid management (2005–2008)

Men aged ≥20 years for whom lipid screening is recommended who have been screened for lipid disorders in the past 5 years

66.6§

Women aged ≥20 years for whom lipid screening is recommended who have been screened for lipid disorders in the past 5 years

74.4§

Men and women aged >20 years for whom lipid screening is recommended who have been screened for lipid disorders in the past 5 years

70.1§

Diabetes management (2007–2010)

Adults aged ≥18 years with diagnosed diabetes whose glycohemoglobin (A1c) is ≤9%

87.1

Tobacco cessation (2005–2008)

Office-based ambulatory care setting visits with screening for tobacco use among adults aged ≥18 years

62.7**

Office-based ambulatory care setting visits with tobacco cessation counseling among current tobacco users in adults aged ≥18 years

20.9**

Office-based ambulatory care setting visits with tobacco cessation medication prescribed among current tobacco users in adults aged ≥18 years

7.6**

Breast cancer screening (2010)

Women aged ≥40 years who had a mammogram within the previous 2 years

75.4††

Women aged 50-74 years who had a mammogram within the previous 2 years

79.7††

Colorectal cancer screening (2010)

Adults aged 50–75 years who have had an FOBT within the past year, sigmoidoscopy within the past 5 years and FOBT within the past 3 years, or colonoscopy within the past 10 years

64.5§§

HIV screening (2005–2008)

Persons aged ≥13 years living with HIV who know they are infected

79.9¶¶

Influenza vaccination (2009)

Adults aged 18–64 years who have received the seasonal influenza vaccine

28.0***

Abbreviations: CVD = cardiovascular disease; FOBT = fecal occult blood test; HIV = human immunodeficiency virus.

* Source: CDC. Recommended use of aspirin and other antiplatelet medications among adults—National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, United States, 2005–2008. In: Use of selected clinical preventive services among adults—United States, 2012. MMWR 2012;61(Suppl; June 15, 2012):11–8.

Source: CDC. Control of hypertension among adults—National Health and Nutrition Examination Survey, United States, 2005–2008. In: Use of selected clinical preventive services among adults—United States, 2012. MMWR 2012;61(Suppl; June 15, 2012):19–25.

§ Source: CDC. Screening for lipid disorders among adults—National Health and Nutrition Examination Survey, United States, 2005–2008. In: Use of selected clinical preventive services among adults—United States, 2012. MMWR 2012;61(Suppl; June 15, 2012):26–31.

Source: CDC. Characteristics associated with poor glycemic control among adults with self-reported diagnosed diabetes—National Health and Nutrition Examination Surveys, United States, 2007–2010. In: Use of selected clinical preventive services among adults—United States, 2012. MMWR 2012;61(Suppl; June 15, 2012):32–7.

** Source: CDC. Tobacco use screening and counseling during physician office visits among adults—National Ambulatory Medical Care Survey and National Health Interview Survey, United States, 2005–2009. In: Use of selected clinical preventive services among adults—United States, 2012. MMWR 2012;61(Suppl; June 15, 2012):38–45.

†† Source: CDC. Breast cancer screening among adult women—Behavioral Risk Factor Surveillance System, United States, 2010. In: Use of selected clinical preventive services among adults—United States, 2012. MMWR 2012;61(Suppl; June 15, 2012):46–50.

§§ Source: CDC. Prevalence of colorectal cancer screening among adults—Behavioral Risk Factor Surveillance System, United States, 2010. In: Use of selected clinical preventive services among adults—United States, 2012. MMWR 2012;61(Suppl; June 15, 2012):51–6.

¶¶ Source: CDC. Prevalence of undiagnosed HIV infection among persons aged ≥13 years—National HIV Surveillance System, United States, 2005–2008. In: Use of selected clinical preventive services among adults—United States, 2012. MMWR 2012;61(Suppl; June 15, 2012):57–63.

*** Source: CDC. Influenza vaccination coverage among adults—National Health Interview Survey, United States, 2008–09 influenza season. In: Use of selected clinical preventive services among adults—United States, 2012. MMWR 2012;61(Suppl; June 15, 2012):64–71.


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