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Prevention

PERSPECTIVE

Putting Prevention In Its Place: The Shift From Clinic To Community

Abstract

 
Despite widespread insurance coverage for adult vaccinations, cancer screening, and cardiovascular disease prevention measures, most U.S. adults are not up to date with these routine services. This paper reports the efforts of Sickness Prevention Achieved through Regional Collaboration (SPARC), a New England–based organization working to broaden delivery of preventive measures throughout its communities. SPARC’s model regards the physician practice as only one element of a network of coordinated prevention activities. SPARC began with the conceptualization of a policy challenge, designed and evaluated interventions to address that problem, and is now influencing public health policies to expand the delivery of clinical preventive services.

More broadly, the Arkansas experience should be read as part of a movement in health care that recognizes the importance of developing interventions outside the medical setting that will nonetheless yield improvements in clinical outcomes. And the Arkansas initiative is likely to have landed in the right place. The school environment is a key site from which to try to adjust the chief propellants of the obesity epidemic: the excessive intake of high-calorie food in combination with insufficient burning off of fat. Other crucial public health challenges demand other forms of collaboration between clinic and community.

Changing the locus of responsibility. In 1994, during the Clinton health care reform efforts, my colleague Michael Alderman and I described in the New York Times what we saw as a major unaddressed but remediable flaw in the U.S. health care system: Too few adults receive the handful of interventions proven to prevent disease and extend life.²

These measures include vaccinations against influenza and pneumococcal disease; screening for cervical, breast, and colon cancers; and screening and treatment of high-risk people to reduce strokes and heart attacks. The services are recommended for men or women over age fifty and are covered by most insurance plans; together they address diseases that account for more than half of the adult mortality in the United States.

We were by no means the first to argue for the need to expand the delivery of routine clinical preventive services. Yet our policy analysis sidestepped the usual suspects: lack of access to medical care, the absence of reminder systems in practitioners’ offices, clinicians’ time constraints, and conflicting guidelines. Important as these impediments are, we focused on one fundamental roadblock: a health care system that relies almost entirely on doctors—that is, the "sick care" system—to vaccinate and screen entire communities.

We argued that as long as responsibility for prevention rests in the hands of those who encounter only a fraction of the population, and whose aim is primarily to treat rather than prevent disease, the potential benefits of delivering effective tools against premature death would never be fully realized. It was time, we contended, to develop local systems that could be accountable for the populationwide delivery of these services.

Launching SPARC. I have learned to be more careful about what I write: Alderman and I were soon challenged to do something about the problem. In 1995 a small community foundation serving four counties at the junction of Connecticut, Massachusetts, and New York asked us to launch an initiative that would be dedicated to increasing the populationwide delivery of clinical preventive services.

After extensive discussions with local health care practitioners, community leaders, and residents, we came up with a plan. We would not compete with practitioners or spawn a parallel prevention system. The goal of this new organization, called Sickness Prevention Achieved through Regional Collaboration (SPARC), would be to overcome local hurdles and exploit untapped opportunities to deliver preventive measures across the community. We would build an organization that would not itself deliver clinical preventive services but would create, coordinate, facilitate, and monitor countywide strategies to increase the use of immunizations and disease screening. Instead of viewing the physician-patient encounter as the beginning and end of a delivery system, SPARC’s approach would regard the physician practice as one element of a communitywide network of activities.

SPARC’s impact. Over the past twelve years, SPARC has made an important impact on the region. Working with Alderman’s board leadership, a small staff, and a highly committed group of local partners including health departments, visiting nurse agencies, and physician offices, we led a broad initiative in 1997 to assure the delivery of pneumococcal vaccinations (PPV) at all community flu-shot clinics. This effort was accompanied by an extensive outreach campaign. Outcomes were monitored by the Connecticut and New York State Medicare quality improvement organizations, which also provided funding for the activity. Using Medicare reimbursement data, we were able to show that the initiative was responsible for doubling the annual PPV delivery in two of our counties.³

With support from the Donaghue Foundation, SPARC developed a mechanism to provide mammography appointments at flu-shot clinics for women who were behind schedule for breast cancer screening. Uninsured women received assistance from a statewide health program for low-income women. Mammogram results were sent to women’s physicians. This simple innovation resulted in a doubling of mammography rates among women attending these flu-shot clinics.⁴ With a larger set of partners and funding from the Robert Wood Johnson Foundation (RWJF), the Centers for Disease Control and Prevention (CDC), and the Health Resources and Services Administration (HRSA), the approach has been deployed across our area and is now being replicated in several communities outside the region.⁵

Other approaches. An enormous amount of creative work with preventive services is also being done in other parts of the country. Churches, beauty salons, barbershops, worksites, and other hubs of activity have all been hitched to the prevention wagon. At SPARC, efforts have also included providing access to preventive services near polling places, delivering hepatitis B vaccinations at public high schools, and creating prevention links with senior centers and Meals-on-Wheels programs.⁶ In 2001 we developed a mechanism to redistribute influenza vaccine between mass immunizers and physician practices to assure the immunization of high-risk patients.⁷ Such strategies are often effective, yet this kind of work is infrequently deployed systematically across a region or connected to multiple elements in the medical infrastructure. At SPARC, we have not yet succeeded in attaining these goals, but we are testing and refining elements of such a model.

Collaboration with the CDC. It is axiomatic that what gets measured gets done. To foster the delivery of multiple disease prevention services, we have developed, with colleagues at the CDC, a composite measure of adults "up to date" with routine services. This summary measure can be used to assess global protection from selected preventable diseases. Drawing on data from the state-based Behavioral Risk Factor Surveillance System (BRFSS), the results of this research have supported our initial belief that clinical preventive services are greatly underused. Despite improvements in the delivery of individual services, more than six of ten Americans age sixty-five and older are still not up to date with routinely recommended vaccinations and cancer screening.⁸ In vulnerable and minority populations, delivery rates are even lower.

Policymakers’ complacency. Yet among many policymakers there is often little sense of urgency about the problem. Imagine this level of performance in another service sector where lives are potentially at stake. Consider, for example, an airline—call it Medic Air—in which all of the aircraft are at least sixty-five years old. How complacent would regulators be if only 40 percent of the aircraft had received the full schedule of preventive maintenance?

Of course, people are not airplanes, and Americans are justifiably protective of their autonomy. But SPARC and other initiatives have shown that a great deal can be done without infringing on individual choice. If preventive services are placed within easy reach across the community, and if health professionals provide straightforward messages about their effectiveness, more Americans will take advantage of their availability.

Encouraging signs. There are encouraging signs that change is coming. The CDC’s Healthy Aging program is working with lead agencies and service groups for older adults to improve the coordination of disease prevention activities across clinical and social service sectors. The SPARC model is an explicit part of that vision.⁹ On the clinical side, the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 enables Medicare beneficiaries who enroll in Medicare Part B to receive a one-time "Welcome to Medicare Visit" within six months of their enrollment.¹⁰ The visit covers vaccinations, screening, and counseling—and this, too, will help.

All health is local. But as the Arkansas initiative reminds us, health issues are local issues. Whose job will it be to manage a problem perched uneasily between medicine and public health? And where will the resources come from, particularly for the uninsured, to treat problems that are uncovered by screening? New communitywide approaches need to be tested and some new resources made available. The CDC’s National Breast and Cervical Cancer Early Detection Program represents one model of a state-based program that can make local assistance available for uninsured women.

THE EFFORT TO EXPAND the delivery of clinical preventive services requires, above all, that policymakers take the step that was so remarkable in Arkansas: the decision by the state’s political leadership to get serious about tackling the problem—to confront the obesity epidemic with imagination, ambition, and all the tools at its disposal.¹¹ If it is too early to speak of success, Arkansas can nonetheless claim that it has accomplished a great deal. The fight for preventive services has much to gain from its example.

Editor's Notes

 
Douglas Shenson (dshenson{at}sparc-health.org) is president of Sickness Prevention Achieved through Regional Collaboration (SPARC) in Lakeville, Connecticut. He is also a visiting associate professor in the Department of Epidemiology and Population Health at the Albert Einstein College of Medicine in the Bronx, New York, and an associate director at the Yale-Griffin Prevention Research Center in Derby, Connecticut.

NOTES

Top NOTES

 

1. K.W. Ryan et al., "Arkansas Fights Fat: Translating Research into Policy to Combat Childhood and Adolescent Obesity," Health Affairs 25, no. 4 (2006): 992–1004.[Abstract/Free Full Text]
2. M. Alderman and D. Shenson, "A Ton of Cure," New York Times, 24 April 1994.
3. D. Shenson et al., "Pneumococcal Immunizations at Flu Clinics: The Impact of Community-Wide Outreach," Journal of Community Health 26, no. 3 (2001): 191–201[CrossRef][Web of Science][Medline]; and D. Shenson et al., "Improving the Delivery of Pneumococcal Vaccinations by Linking Their Promotion and Administration to a Community-based Influenza Shot Campaign" (Presentation at the Thirty-second Annual National Immunization Conference, Atlanta, Georgia, July 1998).
4. D. Shenson et al., "Improving Access to Mammograms through Community-based Influenza Clinics: A Quasi-Experimental Study," American Journal of Preventive Medicine 20, no. 2 (2001): 97–102.[CrossRef][Web of Science][Medline]
5. L.F. Cormier, R.W. Benfer, and D. Shenson, "Expanding Access to Mammograms for Older Rural Women: SPARC’s Community-Wide Approach to Delivery Clinical Preventive Services," 2005 Aetna Susan B. Anthony Award for Excellence in Research on Older Women in Public Health, December 2005, http://www.ph.ucla.edu/ghsnet/Susan_B_Anthony_brochure.pdf (accessed 22 May 2006).
6. Robert Wood Johnson Foundation, Vote and Vaccinate, March 2006, http://www.rwjf.org/reports/npreports/vote.htm (accessed 1 May 2006).
7. D. DiMartino et al., "Redistribution of Influenza Vaccine between Mass Immunizers and Physician Practices to Assure Immunization of High-Risk Patients" (Presentation at the Thirty-fifth Annual National Immunization Conference, Atlanta, Georgia, May 2001).
8. D. Shenson et al., "Are Older Adults Up-to-Date with Cancer Screening and Vaccinations?" Preventing Chronic Disease 2, no. 3 (2005), http://www.cdc.gov/pcd/issues/2005/jul/05_0021.htm (accessed 22 May 2006).
9. J.E. Lang et al., "Healthy Aging: Priorities and Programs of the Centers for Disease Control and Prevention: Public Health at the Federal Level," Generations 29, no. 2 (2005): 24–29.
10. See Centers for Medicare and Medicaid Services, "Preventive Services: One-Time ‘Welcome to Medicare’ Physical Exam," 30 March 2006, http://www.medicare.gov/health/physicalexam.asp (accessed 1 May 2006); and S.H. Woolf and A.B. Coffield, "The ‘Welcome to Medicare’ Visit: A Chance to Raise the Profile of Prevention among Older Adults," British Medical Journal, 12 February 2005, http://bmj.bmjjournals.com/cgi/content/full/330/7487/E337 (accessed 22 May 2006).
11. Ryan et al., "Arkansas Fights Fat."

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