Priorities among recommended clinical preventive services.

BACKGROUND: Many recommended clinical preventive services are delivered at low rates. Decision-makers who wish to improve delivery rates, but face competing demands for finite resources, need information on the relative value of these services. This article describes the results of a systematic assessment of the value of clinical preventive services recommended for average-risk patients by the U.S. Preventive Services Task Force. METHODS: The assessment of services' value for the U.S. population was based on two dimensions: burden of disease prevented by each service and cost effectiveness. Methods were developed for measuring these criteria consistently across different types of services. A companion article describes the methods in greater detail. Each service received 1 to 5 points on each of the two dimensions, for total scores ranging from 2 to 10. Priority opportunities for improving delivery rates were determined by comparing the ranking of services with what is known of current delivery rates nationally. RESULTS: The highest ranked services (scores of 7+) with the lowest delivery rates (< or =50% nationally) are providing tobacco cessation counseling to adults, screening older adults for undetected vision impairments, offering adolescents an anti-tobacco message or advice to quit, counseling adolescents on alcohol and drug abstinence, screening adults for colorectal cancer, screening young women for chlamydial infection, screening adults for problem drinking, and vaccinating older adults against pneumococcal disease. CONCLUSIONS: Decision-makers can use the results to set their own priorities for increasing delivery of clinical preventive services. The methods provide a basis for future priority-setting efforts.

Methods for priority setting among clinical preventive services.

Methods used to compare the value of clinical preventive services based on two criteria-clinically preventable burden (CPB) and cost effectiveness (CE)-are described. A companion article provides rankings of clinical preventive services and discusses its uses for decision-makers; this article focuses on the methods, challenges faced, and solutions. The authors considered all types of data essential to measuring CPB and CE for services recommended by the U.S. Preventive Services Task Force and developed methods essential to ensuring valid comparisons of different services' relative value.

Guide to Community Preventive Services: harnessing the science.

PIP: This article presents reactions in the development of the Guide to Community Preventive Services, which brings public health to the same level of scientific scrutiny with evidence-based recommendations for community prevention services. The first reaction found this development a good change that should be supported, encouraged, and continued. It would help health providers know which practices are based on some level of evidence and which practices warrant more study. The second reaction welcomed the development as a step in the institutionalization of public health, subsequently developing public health systems, standardizing the training of public health workers, and incorporating epidemiology in public health practice. In addition, it is noted that the Guide aggregates the experiences of those who have tried and documented preventive practices. In the third reaction, it is viewed that the Guide would point the way to those activities for which additional attention and study is needed. The fourth reaction indicated that the guidelines would further improve collective knowledge. Finally, the fifth reaction stated that this publication would provide local health departments with an abundance of clear and factual information to plan activities, and educate the community.^ieng

Mortality and morbidity attributable to use of addictive substances in the United States.

Addiction to tobacco, alcohol, and other drugs inflicts a substantial toll on Americans, measurable in terms of deaths and illnesses, social costs, and economic costs. With approximately 60 million smokers, 14 million dependent on alcohol, and 14 million users of illicit drugs, more than one fourth of Americans over age 15 has a physiological dependence on at least one addictive substance. As a result, nearly 590,000 deaths--about a quarter of all deaths in the United States--are caused by addictive substances: 105,000 from alcohol abuse, 446,000 from tobacco use, and 39,000 from addictive drugs in 1995. The magnitude of addiction's impact on morbidity is also great, causing approximately 40 million illnesses and injuries each year. The economic burden of addiction is estimated at greater than $400 billion every year, including health care costs, lost worker productivity, and crime. Less quantifiable, but equally important, are the social costs to families and communities of addiction. Children of substance-abusing parents are more likely as adults to become plagued by addiction and its related problems. Passive exposure to tobacco smoke affects nonsmokers; drug and alcohol abuse are risk factors for crime and incarceration, family violence, fatal and permanently disabling accidents, birth defects, and divorce. Combined, the effects of tobacco, alcohol, and drugs inflict a greater toll on the health and well-being of Americans than any other single preventable factor.

Prevention research and its interface with policy: defining the terms and challenges.

The United States has led the way in the development of new insights into the detection, treatment, and prevention of disease. Not only has the Nation's research community ushered in the virtual elimination of nutrient deficiency diseases, dramatic reductions in childhood vaccine-preventable diseases, and impressive gains against heart disease and stroke, it has also been at the forefront of basic research in genetics and molecular biology and the development of important diagnostic and therapeutic interventions. With health care reform comes an opportunity to build upon and strengthen the positive features of the Nation's health system, including health research--in particular, research that fosters the prevention of health problems and a better informed application of medical services.

Actual causes of death in the United States.

OBJECTIVE: To identify and quantify the major external (nongenetic) factors that contribute to death in the United States. DATA SOURCES: Articles published between 1977 and 1993 were identified through MEDLINE searches, reference citations, and expert consultation. Government reports and complications of vital statistics and surveillance data were also obtained. STUDY SELECTION: Sources selected were those that were often cited and those that indicated a quantitative assessment of the relative contributions of various factors to mortality and morbidity. DATA EXTRACTION: Data used were those for which specific methodological assumptions were stated. A table quantifying the contributions of leading factors was constructed using actual counts, generally accepted estimates, and calculated estimates that were developed by summing various individual estimates and correcting to avoid double counting. For the factors of greatest complexity and uncertainty (diet and activity patterns and toxic agents), a conservative approach was taken by choosing the lower boundaries of the various estimates. DATA SYNTHESIS: The most prominent contributors to mortality in the United States in 1990 were tobacco (an estimated 400,000 deaths), diet and activity patterns (300,000), alcohol (100,000), microbial agents (90,000), toxic agents (60,000), firearms (35,000), sexual behavior (30,000), motor vehicles (25,000), and illicit use of drugs (20,000). Socioeconomic status and access to medical care are also important contributors, but difficult to quantify independent of the other factors cited. Because the studies reviewed used different approaches to derive estimates, the stated numbers should be viewed as first approximations. CONCLUSIONS: Approximately half of all deaths that occurred in 1990 could be attributed to the factors identified. Although no attempt was made to further quantify the impact of these factors on morbidity and quality of life, the public health burden they impose is considerable and offers guidance for shaping health policy priorities.

The year 2000 initiative: implications for comprehensive school health.

Implementing comprehensive school health programs presents one of our nation's key challenges for the 1990s and beyond. Whether we are talking about Goals 2000 or Healthy People 2000, we will meet the challenge only through the combined efforts of the education and health sectors working as partners at the national, state, and community levels and, perhaps most importantly, at the level of the individual elementary and secondary schools.

Objectives for the year 2000.

The Healthy People 2000 initiative challenges the United States to improve the health profile of Americans through a prevention agenda targeting improvements in health status and health service delivery and reduction of risk for disease and disability. Clinical laboratories play an important role in achieving these national health goals and objectives. Many specific objectives directly target improved laboratory services, whereas others are fundamentally dependent on access to better laboratory services. The effectiveness of preventive services (i.e., screening tests, immunizations, and counseling) in reducing morbidity and mortality is well documented. In addition to ensuring quality laboratory services through accurate and reliable screening tests, a unique challenge for clinical laboratories is meeting the critical need for improving communication of complete and necessary laboratory information among laboratories, providers, and patients to enhance patient counseling. The challenges facing clinical laboratories as we approach the year 2000 are complex, but the commitment of the laboratory community is essential.