Update on age-appropriate preventive measures and screening for Canadian primary care providers

Dear Editor,

It is a pity that Shimizu et al. (1) seem to be unaware of the work that has been done in BC over the past decade to develop an evidence-based 'Lifetime Prevention Schedule'. To a large extent the fault lies with us, since we have not published in the academic journals. So as one of the initiators and as founding co-chair (along with Sylvia Robinson) of the Clinical Prevention Policy Review (CPPR) Committee, allow me to provide some basic information about this important work.

Our work began in 2007 because there was a plethora of recommendations from the Canadian and the US Task Forces on preventive care, but no means to prioritise them. Yet it was clear that it would be impossible for a family physican to provide all the preventive services that were recommended in the time available.2 Moreover, there was no policy on a systematic approach to organising and providing a comprehensive set of clinical prevention services in BC (or elsewhere in Canada). I characterised our approach - perhaps somewhat unkindly, but accurately - as 'random acts of kind prevention', an approach that I believe is still largely the case in most other provinces.

In the beginning, the CPPR adopted the following definition of clinical prevention:

Maneuvers pertaining to primary and early secondary prevention (i.e., immunization, screening, counselling and preventive medication as defined above) offered to persons based on age, sex, and risk factors for disease, and delivered on a one-provider-to-one-client basis, with two qualifications:

(i) the provider could work as a member of a care team, or as part of a system tasked with providing, for instance, a screening service; and

(ii)the client could belong to a small group (e.g., a family, a group of smokers) that is jointly benefiting from the service.

We included the four categories of clinical prevention services used by the US Preventive Services Task Force: Immunization, screening, counselling and preventive medication. However, as BC alread had a comprehensive process for adopting an immunisation schedule, we chose not to replicate that work, while acknowledging it as part of the prevention schedule.

The 2009 report of the CPPR3 asked three simple key questions:

1. What is worth doing?

2. What is the best way to provide what is worth doing? (at the practice level)

3. What is the best way to organize/plan/manage the system in order to do what is worth doing? (at the system level).

To answer the first question, we asked a further three questions:4

* What preventive services have been demonstrated to be clinically effective?

* What preventive services are likely to have the greatest impact on population health?

* What preventive services are most cost-effective?

The first of these questions was answered based on Category A recommendations from the Canadian and US Task Forces; for the second and third questions, we turned to the work of Maciosek et al,5 who had developed an assessment method for prioritising clinical prevention using estimates of the clinically preventable burden (CPB) and the cost- effectiveness (CE) of the intervention. They very kindly shared their methodology and tools with us, allowing us to conduct the analyses for BC.

* CPB is defined as the total quality-adjusted life years (QALYs) that could be gained in BC if the clinical prevention service were delivered at recommended intervals to a BC birth cohort of 40,000 individuals over the years of life that a service is recommended

* CE is defined as the average net cost per QALY gained in BC by offering the clinical prevention service at recommended intervals to a BC birth cohort over the recommended age range.

Based on the results of these analyses, a limited set of recommended clinical preventive services were developed; this was called the Lifetime Prevention Schedule (LPS). While some attempt was made to answer the second and third key questions (how best to deliver and support these clinically effective, cost- effective services so they would achieve the expected significant population health impacts), this is still a work in progress. What was clear is that a systematic approach is needed, that electronic medical records need to enable both physician reminders and patient recalls, and that many of the lessons learned from creating systematic approaches to chronic disease management are applicable to the systematic management of clinical prevention.

BC has continued to pursue this important initiative. The LPS has been adopted and the criteria are used to examine any proposed new screening program and to support BC's decisions on screening services; a prevention fee was created for family physicians, and the LPS has been revised and updated; the revised version will shortly be released. BC's Lifetime Prevention Schedule, and the technical work that underpins it, is a 'state of the art' resource that deserves to be more widely known. Moreover, it could readily be adapted to other provinces that want to develop a clinical prevention policy, to ensure that all those eligible receive all the effective clinical prevention services that matter. This will benefit both the individuals and the wider society by reducing the burden of disease, reducing pain and suffering and reducing demand for and the cost of health services.

Yours truly,

Dr. Trevor Hancock, Hon FFPH Professor and Senior Scholar School of Public Health and Social Policy University of Victoria Senior Editor, Canadian Journal of Public Health Tel: 250 472 5374 (Home is better - 250 721 9609) e: Thancock@uvic.ca

References

1. Shimuzu, E, Bouchard, Manon and Mavriplis, C (2016) Update on age- appropriate preventive measures and screening for Canadian primary care providers Can Fam Physician 62:131-8

2. Yarnall, K.S., Pollak, K.I., Ostbye, T., Krause, K.M., & Michener, J.L. (2003) Primary care: Is there enough time for prevention? Am J Public Health, 93(4): 635-641

3. Clinical Prevention Policy Review Committee (2009) A Lifetime of Prevention Victoria BC: Ministry of Health. Available at http://www.health.gov.bc.ca/library/publications/year/2009/CPPR_Lifetime_of_Prevention_Report.pdf

4. Three major technical reports were developed under contract by H. Krueger & Associates Inc. They provided the analysis upon which much of the Committee's final report was based.

5. Maciosek MV, Coffield AB, Edwards NM et al. (2006) Priorities among effective clinical preventive services: results of a systematic review and analysis. Am J Prev Med. 31(1): 52-61.

Conflict of Interest:

None declared