Preventive Healthcare - Wikipedia

14/10/2020 Preventive healthcare - Wikipedia
Preventive healthcare
Preventive healthcare, or prophylaxis, consists of measures
taken for disease prevention.[1] Disease and disability are affected by
environmental factors, genetic predisposition, disease agents, and
lifestyle choices and are dynamic processes which begin before
individuals realize they are affected. Disease prevention relies on
anticipatory actions that can be categorized as primal,[2][3] primary,
secondary, and tertiary prevention.[1]
Each year, millions of people die of preventable deaths. A 2004

study showed that about half of all deaths in the United States in
2000 were due to preventable behaviors and exposures.[4] Leading
causes included cardiovascular disease, chronic respiratory disease,
unintentional injuries, diabetes, and certain infectious diseases.[4]
This same study estimates that 400,000 people die each year in the
United States due to poor diet and a sedentary lifestyle.[4] According
to estimates made by the World Health Organization (WHO), about
55 million people died worldwide in 2011, two thirds of this group
from non-communicable diseases, including cancer, diabetes, and Immunization against diseases is
chronic cardiovascular and lung diseases.[5] This is an increase from a key preventive healthcare
the year 2000, during which 60% of deaths were attributed to these measure.
diseases.[5] Preventive healthcare is especially important given the
worldwide rise in prevalence of chronic diseases and deaths from
these diseases.
There are many methods for prevention of disease. One of them is prevention of teenage smoking
through information giving.[6][7][8][9] It is recommended that adults and children aim to visit their
doctor for regular check-ups, even if they feel healthy, to perform disease screening, identify risk
factors for disease, discuss tips for a healthy and balanced lifestyle, stay up to date with
immunizations and boosters, and maintain a good relationship with a healthcare provider.[10] Some
common disease screenings include checking for hypertension (high blood pressure), hyperglycemia
(high blood sugar, a risk factor for diabetes mellitus), hypercholesterolemia (high blood cholesterol),
screening for colon cancer, depression, HIV and other common types of sexually transmitted disease
such as chlamydia, syphilis, and gonorrhea, mammography (to screen for breast cancer), colorectal
cancer screening, a Pap test (to check for cervical cancer), and screening for osteoporosis. Genetic
testing can also be performed to screen for mutations that cause genetic disorders or predisposition to
certain diseases such as breast or ovarian cancer.[10] However, these measures are not affordable for
every individual and the cost effectiveness of preventive healthcare is still a topic of debate.[11][12]
Contents
Levels of prevention
Primal and primordial prevention
Primary prevention
Secondary prevention
Tertiary prevention
Leading causes of preventable death
United States
https://en.wikipedia.org/wiki/Preventive_healthcare 1/27
Worldwide
Child mortality
Preventive methods
Obesity
Sexually transmitted infections
Malaria prevention using genetic modification
Thrombosis
Cancer
Lung cancer
Skin cancer
Cervical cancer
Colorectal cancer
Health disparities and barriers to accessing care
Economics of lifestyle-based prevention
Effectiveness
Overview
Cost-effectiveness of childhood obesity interventions
Economics of US preventive care
Clinical preventive services & programs
Economics for investment
Health insurance
Evaluating incremental benefits
Economic case
See also
References
External links
Levels of prevention
Preventive healthcare strategies are described as taking place at the primal,[2] primary,[13] secondary,
and tertiary prevention levels. Although advocated as preventive medicine in the early twentieth
century by Sara Josephine Baker,[14] in the 1940s, Hugh R. Leavell and E. Gurney Clark coined the
term primary prevention. They worked at the Harvard and Columbia University Schools of Public
Health, respectively, and later expanded the levels to include secondary and tertiary prevention.
Goldston (1987) notes that these levels might be better described as "prevention, treatment, and
rehabilitation", although the terms primary, secondary, and tertiary prevention are still in use today.
The concept of primal prevention has been created much more recently, in relation to the new
developments in molecular biology over the last fifty years,[15] more particularly in epigenetics, which
point to the paramount importance of environmental conditions - both physical and affective - on the
organism during its fetal and newborn life (or so-called primal period of life).[3]
Level Definition
Primal and Primordial prevention refers to measures designed to avoid the development of risk
primordial
prevention factors in the first place, early in life.[16][17]
Methods to avoid occurrence of disease either through eliminating disease agents or increasing
Primary
resistance to disease.[18] Examples include immunization against disease, maintaining a healthy diet
prevention
and exercise regimen, and avoiding smoking.[19]
Methods to detect and address an existing disease prior to the appearance of symptoms.[18] Examples
Secondary
include treatment of hypertension (a risk factor for many cardiovascular diseases), and cancer
prevention
screenings.[19]
Methods to reduce the harm of symptomatic disease, such as disability or death, through rehabilitation
Tertiary
and treatment.[18] Examples include surgical procedures that halt the spread or progression of
prevention
disease.[18]
Quaternary
Methods to mitigate or avoid results of unnecessary or excessive interventions in the health system[20]
prevention
Primal and primordial prevention
Primal prevention has been propounded as a separate category of health promotion. This health
promotion par excellence[21] is based on knowledge in molecular biology, in particular on epigenetics,
which points to how much affective as well as physical environment during fetal and newborn life may
determine adult health.[22][23][24][25] This way of promoting health consists mainly in providing
future parents with pertinent, unbiased information on primal health and supporting them during
their child's primal period of life (i.e., "from conception to first anniversary" according to definition by
the Primal Health Research Centre, London). This includes adequate parental leave[26] ideally for
both parents with kin caregiving and financial help where needed.
Primordial prevention refers to all measures designed to prevent the development of risk factors in
the first place, early in life,[16][17] and even preconception, as Ruth Etzel has described it "all
population-level actions and measures that inhibit the emergence and establishment of adverse
environmental, economic, and social conditions". This could be reducing air pollution or prohibiting
endocrine-disrupting chemicals in food-handling equipment and food contact materials.[27]
Primary prevention
Primary prevention consists of traditional health promotion and "specific protection."[18] Health
promotion activities are current, non-clinical life choices such as, eating nutritious meals and
exercising daily, that both prevent disease and create a sense of overall well-being. Preventing disease
and creating overall well-being, prolongs life expectancy.[1][18] Health-promotional activities do not
target a specific disease or condition but rather promote health and well-being on a very general
level.[1] On the other hand, specific protection targets a type or group of diseases and complements
the goals of health promotion.[18]
Food is the most basic tool in preventive health care. The 2011 National Health Interview Survey
performed by the Centers for Disease Control was the first national survey to include questions about
ability to pay for food. Difficulty with paying for food, medicine, or both is a problem facing 1 out of 3
Americans. If better food options were available through food banks, soup kitchens, and other
resources for low-income people, obesity and the chronic conditions that come along with it would be
better controlled.[28] A food desert is an area with restricted access to healthy foods due to a lack of
supermarkets within a reasonable distance. These are often low-income neighborhoods with the
majority of residents lacking transportation.[29]

There have been several grassroots movements since
1995 to encourage urban gardening, using vacant lots to grow food cultivated by local residents.[30]
Mobile fresh markets are another resource for residents in a "food desert", which are specially
outfitted buses bringing affordable fresh fruits and vegetables to low-income neighborhoods.[31]
Scientific advancements in genetics have contributed to the knowledge of hereditary diseases and
have facilitated progress in specific protective measures in individuals who are carriers of a disease
gene or have an increased predisposition to a specific disease. Genetic testing has allowed physicians
to make quicker and more accurate diagnoses and has allowed for tailored treatments or personalized
medicine.[1] Similarly, specific protective measures such as water purification, sewage treatment, and
the development of personal hygienic routines (such as regular hand-washing, safe sex to prevent
sexually transmitted infections) became mainstream upon the discovery of infectious disease agents
and have decreased the rates of communicable diseases which are spread in unsanitary conditions.[1]
Secondary prevention
Secondary prevention deals with latent diseases and attempts to prevent an asymptomatic disease
from progressing to symptomatic disease.[18] Certain diseases can be classified as primary or
secondary. This depends on definitions of what constitutes a disease, though, in general, primary
prevention addresses the root cause of a disease or injury[18] whereas secondary prevention aims to
detect and treat a disease early on.[32] Secondary prevention consists of "early diagnosis and prompt
treatment" to contain the disease and prevent its spread to other individuals, and "disability
limitation" to prevent potential future complications and disabilities from the disease.[1] For example,
early diagnosis and prompt treatment for a syphilis patient would include a course of antibiotics to
destroy the pathogen and screening and treatment of any infants born to syphilitic mothers. Disability
limitation for syphilitic patients includes continued check-ups on the heart, cerebrospinal fluid, and
central nervous system of patients to curb any damaging effects such as blindness or paralysis.[1]
Tertiary prevention
Finally, tertiary prevention attempts to reduce the damage caused by symptomatic disease by focusing
on mental, physical, and social rehabilitation. Unlike secondary prevention, which aims to prevent
disability, the objective of tertiary prevention is to maximize the remaining capabilities and functions
of an already disabled patient.[1] Goals of tertiary prevention include: preventing pain and damage,
halting progression and complications from disease, and restoring the health and functions of the
individuals affected by disease.[32] For syphilitic patients, rehabilitation includes measures to prevent
complete disability from the disease, such as implementing work-place adjustments for the blind and
paralyzed or providing counseling to restore normal daily functions to the greatest extent possible.[1]
Leading causes of preventable death
United States
The leading cause of death in the United States was tobacco. However, poor diet and lack of exercise
may soon surpass tobacco as a leading cause of death. These behaviors are modifiable and public
health and prevention efforts could make a difference to reduce these deaths.[4]
Leading causes of preventable deaths in the United States in the year

2000[4]
Cause Deaths caused % of all deaths
Tobacco smoking 435,000 18.1
Poor diet and physical inactivity 400,000 16.6
Alcohol consumption 85,000 3.5
Infectious diseases 75,000 3.1
Toxicants 55,000 2.3
Traffic collisions 43,000 1.8
Firearm incidents 29,000 1.2
Sexually transmitted infections 20,000 0.8
Drug abuse 17,000 0.7
Worldwide
The leading causes of preventable death worldwide share similar trends to the United States. There
are a few differences between the two, such as malnutrition, pollution, and unsafe sanitation, that
reflect health disparities between the developing and developed world.[33]
Leading causes of preventable death worldwide as of the year 2001[33]

Cause Deaths caused (millions per year)
Hypertension 7.8
Smoking 5.0
High cholesterol 3.9
Malnutrition 3.8
Sexually transmitted infections 3.0
Poor diet 2.8
Overweight and obesity 2.5
Physical inactivity 2.0
Alcohol 1.9
Indoor air pollution from solid fuels 1.8
Unsafe water and poor sanitation 1.6
Child mortality
In 2010, 7.6 million children died before reaching the age of 5. While this is a decrease from
9.6 million in the year 2000,[34] it was still far from the fourth Millennium Development Goal to
decrease child mortality by two-thirds by the year 2015.[35] Of these deaths, about 64% were due to
infection including diarrhea, pneumonia, and malaria.[34] About 40% of these deaths occurred in
neonates (children ages 1–28 days) due to pre-term birth complications.[35] The highest number of
child deaths occurred in Africa and Southeast Asia.[34] As of 2015 in Africa, almost no progress has
been made in reducing neonatal death since 1990.[35] In 2010, India, Nigeria, Democratic Republic of
the Congo, Pakistan, and China contributed to almost 50% of global child deaths. Targeting efforts in
these countries is essential to reducing the global child death rate.[34]
Child mortality is caused by factors including poverty, environmental hazards, and lack of maternal
education.[36] In 2003, the World Health Organization created a list of interventions in the following
table that were judged economically and operationally "feasible," based on the healthcare resources
and infrastructure in 42 nations that contribute to 90% of all infant and child deaths. The table
indicates how many infant and child deaths could have been prevented in the year 2000, assuming
universal healthcare coverage.[36]
Leading preventive interventions as of 2003 reducing deaths in children 0–5 years old worldwide[36]
Intervention Percent of all child deaths preventable
Breastfeeding 13
Insecticide-treated materials 7
Complementary feeding 6
Zinc 4
Clean delivery 4
Hib vaccine 4
Water, sanitation, hygiene 3
Antenatal steroids 3
Newborn temperature management 2
Vitamin A 2
Tetanus toxoid 2
Nevirapine and replacement feeding 2
Antibiotics for premature rupture of membranes 1
Measles vaccine 1
Antimalarial intermittent preventive treatment in pregnancy <1%
Preventive methods
Obesity
Obesity is a major risk factor for a wide variety of conditions including cardiovascular diseases,
hypertension, certain cancers, and type 2 diabetes. In order to prevent obesity, it is recommended
that individuals adhere to a consistent exercise regimen as well as a nutritious and balanced diet. A
healthy individual should aim for acquiring 10% of their energy from proteins, 15-20% from fat, and
over 50% from complex carbohydrates, while avoiding alcohol as well as foods high in fat, salt, and
sugar.[37] Sedentary adults should aim for at least half an hour of moderate-level daily physical
activity and eventually increase to include at least 20 minutes of intense exercise, three times a
week.[38] Preventive health care offers many benefits to those that chose to participate in taking an
active role in the culture. The medical system in our society is geared toward curing acute symptoms
of disease after the fact that they have brought us into the emergency room. An ongoing epidemic
within American culture is the prevalence of obesity. Healthy eating and regular exercise play a
significant role in reducing an individual's risk for type 2 diabetes. A 2008 study concluded that about
23.6 million people in the United States had diabetes, including 5.7 million that had not been
diagnosed. Ninety to 95 percent of people with diabetes have type 2 diabetes. Diabetes is the main
cause of kidney failure, limb amputation, and new-onset blindness in American adults.[39]
Sexually transmitted infections

Sexually transmitted infections (STIs), such as syphilis and HIV,

are common but preventable with safe-sex practices. STIs can be
asymptomatic, or cause a range of symptoms. Preventive
measures for STIs are called prophylactics. The term especially
applies to the use of condoms,[40] which are highly effective at
preventing disease,[41] but also to other devices meant to prevent
STIs,[40] such as dental dams and latex gloves. Other means for
preventing STIs include education on how to use condoms or
other such barrier devices, testing partners before having
unprotected sex, receiving regular STI screenings, to both receive
U.S. propaganda poster Fool the
treatment and prevent spreading STIs to partners, and,
Axis Use Prophylaxis, 1942
specifically for HIV, regularly taking prophylactic antiretroviral
drugs, such as Truvada. Post-exposure prophylaxis, started within
72 hours (optimally less than 1 hour) after exposure to high-risk
fluids, can also protect against HIV transmission.
Malaria prevention using genetic modification
Genetically modified mosquitoes are being used in developing countries to control malaria. This
approach has been subject to objections and controversy.[42]
Thrombosis
Thrombosis is a serious circulatory disease affecting thousands, usually older persons undergoing
surgical procedures, women taking oral contraceptives and travelers. The consequences of thrombosis
can be heart attacks and strokes. Prevention can include: exercise, anti-embolism stockings,
pneumatic devices, and pharmacological treatments.
Cancer
In recent years, cancer has become a global problem. Low and middle income countries share a
majority of the cancer burden largely due to exposure to carcinogens resulting from industrialization
and globalization.[43] However, primary prevention of cancer and knowledge of cancer risk factors
can reduce over one third of all cancer cases. Primary prevention of cancer can also prevent other
diseases, both communicable and non-communicable, that share common risk factors with cancer.[43]
Lung cancer
Lung cancer is the leading cause of cancer-related deaths in the

United States and Europe and is a major cause of death in other
countries.[44] Tobacco is an environmental carcinogen and the
major underlying cause of lung cancer.[44] Between 25% and 40%
of all cancer deaths and about 90% of lung cancer cases are
associated with tobacco use. Other carcinogens include asbestos
and radioactive materials.[45] Both smoking and second-hand
exposure from other smokers can lead to lung cancer and
Distribution of lung cancer in the
eventually death.[44] Therefore, prevention of tobacco use is
United States
paramount to prevention of lung cancer.
Individual, community, and statewide interventions can prevent or cease tobacco use. 90% of adults
in the US who have ever smoked did so prior to the age of 20. In-school prevention/educational
programs, as well as counseling resources, can help prevent and cease adolescent smoking.[45] Other
cessation techniques include group support programs, nicotine replacement therapy (NRT), hypnosis,
and self-motivated behavioral change. Studies have shown long term success rates (>1 year) of 20%
for hypnosis and 10%-20% for group therapy.[45]
Cancer screening programs serve as effective sources of secondary prevention. The Mayo Clinic,
Johns Hopkins, and Memorial Sloan-Kettering hospitals conducted annual x-ray screenings and
sputum cytology tests and found that lung cancer was detected at higher rates, earlier stages, and had
more favorable treatment outcomes, which supports widespread investment in such programs.[45]
Legislation can also affect smoking prevention and cessation. In 1992, Massachusetts (United States)
voters passed a bill adding an extra 25 cent tax to each pack of cigarettes, despite intense lobbying and
$7.3 million spent by the tobacco industry to oppose this bill. Tax revenue goes toward tobacco
education and control programs and has led to a decline of tobacco use in the state.[46]
Lung cancer and tobacco smoking are increasing worldwide, especially in China. China is responsible
for about one-third of the global consumption and production of tobacco products.[47] Tobacco
control policies have been ineffective as China is home to 350 million regular smokers and
750 million passive smokers and the annual death toll is over 1 million.[47] Recommended actions to
reduce tobacco use include: decreasing tobacco supply, increasing tobacco taxes, widespread
educational campaigns, decreasing advertising from the tobacco industry, and increasing tobacco
cessation support resources.[47] In Wuhan, China, a 1998 school-based program implemented an
anti-tobacco curriculum for adolescents and reduced the number of regular smokers, though it did
not significantly decrease the number of adolescents who initiated smoking. This program was
therefore effective in secondary but not primary prevention and shows that school-based programs
have the potential to reduce tobacco use.[48]
Skin cancer
Skin cancer is the most common cancer in the United States.[49]

The most lethal form of skin cancer, melanoma, leads to over
50,000 annual deaths in the United States.[49] Childhood
prevention is particularly important because a significant portion
of ultraviolet radiation exposure from the sun occurs during
childhood and adolescence and can subsequently lead to skin
cancer in adulthood. Furthermore, childhood prevention can lead
to the development of healthy habits that continue to prevent
cancer for a lifetime.[49]
The Centers for Disease Control and Prevention (CDC)

recommends several primary prevention methods including:
An image of melanoma, one of the
limiting sun exposure between 10 AM and 4 PM, when the sun is deadliest forms of skin cancer
strongest, wearing tighter-weave natural cotton clothing, wide-
brim hats, and sunglasses as protective covers, using sunscreens
that protect against both UV-A and UV-B rays, and avoiding tanning salons.[49] Sunscreen should be
reapplied after sweating, exposure to water (through swimming for example) or after several hours of
sun exposure.[49] Since skin cancer is very preventable, the CDC recommends school-level prevention
programs including preventive curricula, family involvement, participation and support from the
school's health services, and partnership with community, state, and national agencies and
organizations to keep children away from excessive UV radiation exposure.[49]
Most skin cancer and sun protection data comes from Australia and the United States.[50] An
international study reported that Australians tended to demonstrate higher knowledge of sun
protection and skin cancer knowledge, compared to other countries.[50] Of children, adolescents, and
adults, sunscreen was the most commonly used skin protection. However, many adolescents
purposely used sunscreen with a low sun protection factor (SPF) in order to get a tan.[50] Various
Australian studies have shown that many adults failed to use sunscreen correctly; many applied
sunscreen well after their initial sun exposure and/or failed to reapply when necessary.[51][52][53] A
2002 case-control study in Brazil showed that only 3% of case participants and 11% of control
participants used sunscreen with SPF >15.[54]
Cervical cancer
Cervical cancer ranks among the top three most common cancers
among women in Latin America, sub-Saharan Africa, and parts of
Asia. Cervical cytology screening aims to detect abnormal lesions
in the cervix so that women can undergo treatment prior to the
development of cancer. Given that high quality screening and
follow-up care has been shown to reduce cervical cancer rates by
up to 80%, most developed countries now encourage sexually
active women to undergo a Pap test every 3–5 years. Finland and
Iceland have developed effective organized programs with routine
monitoring and have managed to significantly reduce cervical The presence of cancer
cancer mortality while using fewer resources than unorganized, (adenocarcinoma) detected on a
opportunistic programs such as those in the United States or Pap test
Canada.[55]
In developing nations in Latin America, such as Chile, Colombia, Costa Rica, and Cuba, both public
and privately organized programs have offered women routine cytological screening since the 1970s.
However, these efforts have not resulted in a significant change in cervical cancer incidence or
mortality in these nations. This is likely due to low quality, inefficient testing. However, Puerto Rico,
which has offered early screening since the 1960s, has witnessed almost a 50% decline in cervical
cancer incidence and almost a four-fold decrease in mortality between 1950 and 1990. Brazil, Peru,
India, and several high-risk nations in sub-Saharan Africa which lack organized screening programs,
have a high incidence of cervical cancer.[55]
Colorectal cancer
Colorectal cancer is globally the second most common cancer in women and the third-most common
in men,[56] and the fourth most common cause of cancer death after lung, stomach, and liver
cancer,[57] having caused 715,000 deaths in 2010.[58]
It is also highly preventable; about 80 percent[59] of colorectal cancers begin as benign growths,
commonly called polyps, which can be easily detected and removed during a colonoscopy. Other
methods of screening for polyps and cancers include fecal occult blood testing. Lifestyle changes that
may reduce the risk of colorectal cancer include increasing consumption of whole grains, fruits and
vegetables, and reducing consumption of red meat (see Colorectal cancer).
Health disparities and barriers to accessing care

Access to healthcare and preventive health services is unequal, as is the quality of care received. A
study conducted by the Agency for Healthcare Research and Quality (AHRQ) revealed health
disparities in the United States. In the United States, elderly adults (>65 years old) received worse
care and had less access to care than their younger counterparts. The same trends are seen when
comparing all racial minorities (black, Hispanic, Asian) to white patients, and low-income people to
high-income people.[60] Common barriers to accessing and utilizing healthcare resources included
lack of income and education, language barriers, and lack of health insurance. Minorities were less
likely than whites to possess health insurance, as were individuals who completed less education.
These disparities made it more difficult for the disadvantaged groups to have regular access to a
primary care provider, receive immunizations, or receive other types of medical care.[60] Additionally,
uninsured people tend to not seek care until their diseases progress to chronic and serious states and
they are also more likely to forgo necessary tests, treatments, and filling prescription medications.[61]
These sorts of disparities and barriers exist worldwide as well. Often, there are decades of gaps in life
expectancy between developing and developed countries. For example, Japan has an average life
expectancy that is 36 years greater than that in Malawi.[62] Low-income countries also tend to have
fewer physicians than high-income countries. In Nigeria and Myanmar, there are fewer than 4
physicians per 100,000 people while Norway and Switzerland have a ratio that is ten-fold higher.[62]
Common barriers worldwide include lack of availability of health services and healthcare providers in
the region, great physical distance between the home and health service facilities, high transportation
costs, high treatment costs, and social norms and stigma toward accessing certain health services.[63]
Economics of lifestyle-based prevention

With lifestyle factors such as diet and exercise rising to the top of preventable death statistics, the
economics of healthy lifestyle is a growing concern. There is little question that positive lifestyle
choices provide an investment in health throughout life.[64] To gauge success, traditional measures
such as the quality years of life method (QALY), show great value.[65] However, that method does not
account for the cost of chronic conditions or future lost earnings because of poor health.[66]
Developing future economic models that would guide both private and public investments as well as
drive future policy to evaluate the efficacy of positive lifestyle choices on health is a major topic for
economists globally.
US Americans spend over three trillion a year on health care but have a higher rate of infant mortality,
shorter life expectancies, and a higher rate of diabetes than other high-income nations because of
negative lifestyle choices.[67] Despite these large costs, very little is spent on prevention for lifestyle-
caused conditions in comparison. In 2016, the Journal of the American Medical Association
estimated that $101 billion was spent in 2013 on the preventable disease of diabetes, and another
$88 billion was spent on heart disease.[68] In an effort to encourage healthy lifestyle choices, as of
2010 workplace wellness programs were on the rise but the economics and effectiveness data were
continuing to evolve and develop.[69]
Health insurance coverage impacts lifestyle choices, even intermittent loss of coverage had negative
effects on healthy choices in the US.[70] The repeal of the Affordable Care Act (ACA) could
significantly impact coverage for many Americans, as well as “The Prevention and Public Health
Fund” which is the US first and only mandatory funding stream dedicated to improving public
health[71] including counseling on lifestyle prevention issues, such as weight management, alcohol
use, and treatment for depression.[72]
Because in the US chronic illnesses predominate as a cause of death and pathways for treating chronic
illnesses are complex and multifaceted, prevention is a best practice approach to chronic disease
when possible. In many cases, prevention requires mapping complex pathways[73] to determine the
ideal point for intervention. Cost-effectiveness of prevention is achievable, but impacted by the length
of time it takes to see effects/outcomes of intervention. This makes prevention efforts difficult to fund
—particularly in strained financial contexts. Prevention potentially creates other costs as well, due to
extending the lifespan and thereby increasing opportunities for illness. In order to assess the cost-
effectiveness of prevention, the cost of the preventive measure, savings from avoiding morbidity, and
the cost from extending the lifespan need to be considered.[74] Life extension costs become smaller
when accounting for savings from postponing the last year of life,[75] which makes up a large fraction
of lifetime medical expenditures[76] and becomes cheaper with age.[77] Prevention leads to savings
only if the cost of the preventive measure is less than the savings from avoiding morbidity net of the
cost of extending the life span. In order to establish reliable economics of prevention[78] for illnesses
that are complicated in origin, knowing how best to assess prevention efforts, i.e. developing useful
measures and appropriate scope, is required.
Effectiveness
Overview
There is no general consensus as to whether or not preventive healthcare measures are cost-effective,
but they increase the quality of life dramatically. There are varying views on what constitutes a "good
investment." Some argue that preventive health measures should save more money than they cost,
when factoring in treatment costs in the absence of such measures.[11] Others have argued in favor of
"good value" or conferring significant health benefits even if the measures do not save money.[79]
Furthermore, preventive health services are often described as one entity though they comprise a
myriad of different services, each of which can individually lead to net costs, savings, or neither.
Greater differentiation of these services is necessary to fully understand both the financial and health
effects.[11]
A 2010 study reported that in the United States, vaccinating children, cessation of smoking, daily
prophylactic use of aspirin, and screening of breast and colorectal cancers had the most potential to
prevent premature death.[11] Preventive health measures that resulted in savings included vaccinating
children and adults, smoking cessation, daily use of aspirin, and screening for issues with alcoholism,
obesity, and vision failure.[11] These authors estimated that if usage of these services in the United
States increased to 90% of the population, there would be net savings of $3.7 billion, which comprised
only about -0.2% of the total 2006 United States healthcare expenditure.[11] Despite the potential for
decreasing healthcare spending, utilization of healthcare resources in the United States still remains
low, especially among Latinos and African-Americans.[80] Overall, preventive services are difficult to
implement because healthcare providers have limited time with patients and must integrate a variety
of preventive health measures from different sources.[80]
While these specific services bring about small net savings not every preventive health measure saves
more than it costs. A 1970s study showed that preventing heart attacks by treating hypertension early
on with drugs actually did not save money in the long run. The money saved by evading treatment
from heart attack and stroke only amounted to about a quarter of the cost of the drugs.[81][82]
Similarly, it was found that the cost of drugs or dietary changes to decrease high blood cholesterol
exceeded the cost of subsequent heart disease treatment.[83][84] Due to these findings, some argue
that rather than focusing healthcare reform efforts exclusively on preventive care, the interventions
that bring about the highest level of health should be prioritized.[79]
In 2008, Cohen et al. outlined a few arguments made by skeptics of preventive healthcare. Many
argue that preventive measures only cost less than future treatment when the proportion of the
population that would become ill in the absence of prevention is fairly large.[12] The Diabetes
Prevention Program Research Group conducted a 2012 study evaluating the costs and benefits in
quality-adjusted life-years or QALYs of lifestyle changes versus taking the drug metformin. They
found that neither method brought about financial savings, but were cost-effective nonetheless
because they brought about an increase in QALYs.[85] In addition to scrutinizing costs, preventive
healthcare skeptics also examine efficiency of interventions. They argue that while many treatments
of existing diseases involve use of advanced equipment and technology, in some cases, this is a more
efficient use of resources than attempts to prevent the disease.[12] Cohen suggested that the
preventive measures most worth exploring and investing in are those that could benefit a large
portion of the population to bring about cumulative and widespread health benefits at a reasonable
cost.[12]
Cost-effectiveness of childhood obesity interventions
There are at least four nationally implemented childhood obesity interventions in the United States:
the Sugar-Sweetened Beverage excise tax (SSB), the TV AD program, active physical education (Active
PE) policies, and early care and education (ECE) policies.[86] They each have similar goals of reducing
childhood obesity. The effects of these interventions on BMI have been studied, and the cost-
effectiveness analysis (CEA) has led to a better understanding of projected cost reductions and
improved health outcomes.[87][88] The Childhood Obesity Intervention Cost-Effectiveness Study
(CHOICES) was conducted to evaluate and compare the CEA of these four interventions.[86]
Gortmaker, S.L. et al. (2015) states: "The four initial interventions were selected by the investigators
to represent a broad range of nationally scalable strategies to reduce childhood obesity using a mix of
both policy and programmatic strategies... 1. an excise tax of $0.01 per ounce of sweetened beverages,
applied nationally and administered at the state level (SSB), 2. elimination of the tax deductibility of
advertising costs of TV advertisements for "nutritionally poor" foods and beverages seen by children
and adolescents (TV AD), 3. state policy requiring all public elementary schools in which physical
education (PE) is currently provided to devote ≥50% of PE class time to moderate and vigorous
physical activity (Active PE), and 4. state policy to make early child educational settings healthier by
increasing physical activity, improving nutrition, and reducing screen time (ECE)."
The CHOICES found that SSB, TV AD, and ECE led to net cost savings. Both SSB and TV AD
increased quality adjusted life years and produced yearly tax revenue of 12.5 billion US dollars and
80 million US dollars, respectively.
Some challenges with evaluating the effectiveness of child obesity interventions include:
1. The economic consequences of childhood obesity are both short and long term. In the short term,
obesity impairs cognitive achievement and academic performance. Some believe this is
secondary to negative effects on mood or energy, but others suggest there may be physiological
factors involved.[89] Furthermore, obese children have increased health care expenses (e.g.
medications, acute care visits). In the long term, obese children tend to become obese adults with
associated increased risk for a chronic condition such as diabetes or hypertension.[90][91] Any
effect on their cognitive development may also affect their contributions to society and
socioeconomic status.
2. In the CHOICES, it was noted that translating the effects of these interventions may in fact differ
among communities throughout the nation. In addition it was suggested that limited outcomes are
studied and these interventions may have an additional effect that is not fully appreciated.
3. Modeling outcomes in such interventions in children over the long term is challenging because
advances in medicine and medical technology are unpredictable. The projections from cost-
effective analysis may need to be reassessed more frequently.
Economics of US preventive care
As of 2009, the cost-effectiveness of preventive care is a highly debated topic. While some economists
argue that preventive care is valuable and potentially cost saving, others believe it is an inefficient
waste of resources.[92] Preventive care is composed of a variety of clinical services and programs
including annual doctor's check-ups, annual immunizations, and wellness programs; recent models
show that these simple interventions can have significant economic impacts.[65]
Clinical preventive services & programs
Research on preventive care addresses the question of whether it is cost saving or cost effective and
whether there is an economics evidence base for health promotion and disease prevention. The need
for and interest in preventive care is driven by the imperative to reduce health care costs while
improving quality of care and the patient experience. Preventive care can lead to improved health
outcomes and cost savings potential. Services such as health assessments/screenings, prenatal care,
and telehealth and telemedicine can reduce morbidity or mortality with low cost or cost
savings.[93][94] Specifically, health assessments/screenings have cost savings potential, with varied
cost-effectiveness based on screening and assessment type.[95] Inadequate prenatal care can lead to
an increased risk of prematurity, stillbirth, and infant death.[96] Time is the ultimate resource and
preventive care can help mitigate the time costs.[97] Telehealth and telemedicine is one option that
has gained consumer interest, acceptance and confidence and can improve quality of care and patient
satisfaction.[98]
Economics for investment
There are benefits and trade-offs when considering investment in preventive care versus other types
of clinical services. Preventive care can be a good investment as supported by the evidence base and
can drive population health management objectives.[12][94] The concepts of cost saving and cost-
effectiveness are different and both are relevant to preventive care. For example, preventive care that
may not save money may still provide health benefits. Thus, there is a need to compare interventions
relative to impact on health and cost.[99]
Preventive care transcends demographics and is applicable to people of every age. The Health Capital
Theory underpins the importance of preventive care across the lifecycle and provides a framework for
understanding the variances in health and health care that are experienced. It treats health as a stock
that provides direct utility. Health depreciates with age and the aging process can be countered
through health investments. The theory further supports that individuals demand good health, that
the demand for health investment is a derived demand (i.e. investment is health is due to the
underlying demand for good health), and the efficiency of the health investment process increases
with knowledge (i.e. it is assumed that the more educated are more efficient consumers and producers
of health).[100]
The prevalence elasticity of demand for prevention can also provide insights into the economics.
Demand for preventive care can alter the prevalence rate of a given disease and further reduce or even
reverse any further growth of prevalence.[97] Reduction in prevalence subsequently leads to reduction
in costs.
There are a number of organizations and policy actions that are relevant when discussing the
economics of preventive care services. The evidence base, viewpoints, and policy briefs from the
Robert Wood Johnson Foundation, the Organisation for Economic Co-operation and Development
(OECD), and efforts by the U.S. Preventive Services Task Force (USPSTF) all provide examples that
improve the health and well-being of populations (e.g. preventive health assessments/screenings,
prenatal care, and telehealth/telemedicine). The Patient Protection and Affordable Care Act (PPACA,
ACA) has major influence on the provision of preventive care services, although it is currently under
heavy scrutiny and review by the new administration. According to the Centers for Disease Control
and Prevention (CDC), the ACA makes preventive care affordable and accessible through mandatory
coverage of preventive services without a deductible, copayment, coinsurance, or other cost
sharing.[101]
The U.S. Preventive Services Task Force (USPSTF), a panel of national experts in prevention and
evidence-based medicine, works to improve health of Americans by making evidence-based
recommendations about clinical preventive services.[102] They do not consider the cost of a preventive
service when determining a recommendation. Each year, the organization delivers a report to
Congress that identifies critical evidence gaps in research and recommends priority areas for further
review.[103]
The National Network of Perinatal Quality Collaboratives (NNPQC), sponsored by the CDC, supports
state-based perinatal quality collaboratives (PQCs) in measuring and improving upon health care and
health outcomes for mothers and babies. These PQCs have contributed to improvements such as
reduction in deliveries before 39 weeks, reductions in healthcare associated blood stream infections,
and improvements in the utilization of antenatal corticosteroids.[104]
Telehealth and telemedicine has realized significant growth and development recently. The Center for
Connected Health Policy (The National Telehealth Policy Resource Center) has produced multiple
reports and policy briefs on the topic of Telehealth and Telemedicine and how they contribute to
preventive services.[105]
Policy actions and provision of preventive services do not guarantee utilization. Reimbursement has
remained a significant barrier to adoption due to variances in payer and state level reimbursement
policies and guidelines through government and commercial payers. Americans use preventive
services at about half the recommended rate and cost-sharing, such as deductibles, co-insurance, or
copayments, also reduce the likelihood that preventive services will be used.[101] Further, despite the
ACA's enhancement of Medicare benefits and preventive services, there were no effects on preventive
service utilization, calling out the fact that other fundamental barriers exist.[106]
The Affordable Care Act and preventive healthcare
The Patient Protection and Affordable Care Act, also known as just the Affordable Care Act or
Obamacare, was passed and became law in the United States on March 23, 2010.[107] The finalized
and newly ratified law was to address many issues in the U.S. healthcare system, which included
expansion of coverage, insurance market reforms, better quality, and the forecast of efficiency and
costs.[108] Under the insurance market reforms the act required that insurance companies no longer
exclude people with pre-existing conditions, allow for children to be covered on their parents' plan
until the age of 26, and expand appeals that dealt with reimbursement denials. The Affordable Care
Act also banned the limited coverage imposed by health insurances, and insurance companies were to
include coverage for preventive health care services.[109] The U.S. Preventive Services Task Force has
categorized and rated preventive health services as either ‘”A” or “B”, as to which insurance
companies must comply and present full coverage. Not only has the U.S. Preventive Services Task
Force provided graded preventive health services that are appropriate for coverage, they have also
provided many recommendations to clinicians and insurers to promote better preventive care to
ultimately provide better quality of care and lower the burden of costs.[110]
Health insurance
Healthcare insurance companies are willing to pay for preventive care despite the fact that patients
are not acutely sick in hope that it will prevent them from developing a chronic disease later on in
life.[111] Today, health insurance plans offered through the Marketplace, mandated by the Affordable
Care Act are required to provide certain preventive care services free of charge to patients. Section
2713 (https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/aca_implementation_faqs12.h
tml) of the Affordable Care Act, specifies that all private Marketplace and all employer-sponsored
private plans (except those grandfathered in) are required to cover preventive care services that are
ranked A or B by the US Preventive Services Task Force free of charge to patients.[112][113] For
example, UnitedHealthcare insurance company has published patient guidelines at the beginning of
the year explaining their preventive care coverage.[114]
Evaluating incremental benefits
Evaluating the incremental benefits of preventive care requires a longer period of time when
compared to acutely ill patients. Inputs into the model such as discounting rate and time horizon can
have significant effects on the results. One controversial subject is use of a 10-year time frame to
assess cost effectiveness of diabetes preventive services by the Congressional Budget Office.[115]
Preventive care services mainly focus on chronic disease.[116] The Congressional Budget Office has
provided guidance that further research is needed in the area of the economic impacts of obesity in
the US before the CBO can estimate budgetary consequences. A bipartisan report published in May
2015 recognizes the potential of preventive care to improve patients' health at individual and
population levels while decreasing the healthcare expenditure.[117]
Economic case
Mortality from modifiable risk factors
Chronic diseases such as heart disease, stroke, diabetes, obesity and cancer have become the most
common and costly health problems in the United States. In 2014, it was projected that by 2023 that
the number of chronic disease cases would increase by 42%, resulting in $4.2 trillion in treatment and
lost economic output.[118] They are also among the top ten leading causes of mortality.[119] Chronic
diseases are driven by risk factors that are largely preventable. Sub-analysis performed on all deaths
in the United States in the year 2000 revealed that almost half were attributed to preventable
behaviors including tobacco, poor diet, physical inactivity and alcohol consumption.[120] More recent
analysis reveals that heart disease and cancer alone accounted for nearly 46% of all deaths.[121]
Modifiable risk factors are also responsible for a large morbidity burden, resulting in poor quality of
life in the present and loss of future life earning years. It is further estimated that by 2023, focused
efforts on the prevention and treatment of chronic disease may result in 40 million fewer chronic
disease cases, potentially reducing treatment costs by $220 billion.[118]
Childhood vaccinations
Childhood immunizations are largely responsible for the increase in life expectancy in the 20th
century. From an economic standpoint, childhood vaccines demonstrate a very high return on
investment.[120] According to Healthy People 2020, for every birth cohort that receives the routine
childhood vaccination schedule, direct health care costs are reduced by $9.9 billion and society saves
$33.4 billion in indirect costs.[122] The economic benefits of childhood vaccination extend beyond
individual patients to insurance plans and vaccine manufacturers, all while improving the health of
the population.[123]
Health capital theory
The burden of preventable illness extends beyond the healthcare sector, incurring costs related to lost
productivity among workers in the workforce. Indirect costs related to poor health behaviors and
associated chronic disease costs U.S. employers billions of dollars each year.
According to the American Diabetes Association (ADA),[124] medical costs for employees with
diabetes are twice as high as for workers without diabetes and are caused by work-related
absenteeism ($5 billion), reduced productivity at work ($20.8 billion), inability to work due to illness-
related disability ($21.6 billion), and premature mortality ($18.5 billion). Reported estimates of the
cost burden due to increasingly high levels of overweight and obese members in the workforce
vary,[125] with best estimates suggesting 450 million more missed work days, resulting in $153 billion
each year in lost productivity, according to the CDC Healthy Workforce.[126]
The Health Capital model explains how individual investments in health can increase earnings by
“increasing the number of healthy days available to work and to earn income.”[127] In this context,
health can be treated both as a consumption good, wherein individuals desire health because it
improves quality of life in the present, and as an investment good because of its potential to increase
attendance and workplace productivity over time. Preventive health behaviors such as healthful diet,
regular exercise, access to and use of well-care, avoiding tobacco, and limiting alcohol can be viewed
as health inputs that result in both a healthier workforce and substantial cost savings.
Quality adjusted life years
Health benefits of preventive care measures can be described in terms of quality-adjusted life-years
(QALYs) saved. A QALY takes into account length and quality of life, and is used to evaluate the cost-
effectiveness of medical and preventive interventions. Classically, one year of perfect health is defined
as 1 QALY and a year with any degree of less than perfect health is assigned a value between 0 and 1
QALY.[128] As an economic weighting system, the QALY can be used to inform personal decisions, to
evaluate preventive interventions and to set priorities for future preventive efforts.
Cost-saving and cost-effective benefits of preventive care measures are well established. The Robert
Wood Johnson Foundation evaluated the prevention cost-effectiveness literature, and found that
many preventive measures meet the benchmark of <$100,000 per QALY and are considered to be
favorably cost-effective (https://www.rwjf.org/en/library/research/2009/09/cost-savings-and-cost-e
ffectiveness-of-clinical-preventive-care.html). These include screenings for HIV and chlamydia,
cancers of the colon, breast and cervix, vision screening, and screening for abdominal aortic
aneurysms in men >60 in certain populations. Alcohol and tobacco screening were found to be cost-
saving in some reviews and cost-effective in others. According to the RWJF analysis, two preventive
interventions were found to save costs in all reviews: childhood immunizations and counseling adults
on the use of aspirin.
Minority populations
Health disparities are increasing in the United States for chronic diseases such as obesity, diabetes,
cancer, and cardiovascular disease. Populations at heightened risk for health inequities are the
growing proportion of racial and ethnic minorities, including African Americans, American Indians,
Hispanics/Latinos, Asian Americans, Alaska Natives and Pacific Islanders.[129]
According to the Racial and Ethnic Approaches to Community Health (REACH) (https://www.cdc.go
v/nccdphp/dnpao/state-local-programs/reach/), a national CDC program, non-Hispanic blacks
currently have the highest rates of obesity (48%), and risk of newly diagnosed diabetes is 77% higher
among non-Hispanic blacks, 66% higher among Hispanics/Latinos and 18% higher among Asian
Americans compared to non-Hispanic whites. Current U.S. population projections predict that more
than half of Americans will belong to a minority group by 2044.[130] Without targeted preventive
interventions, medical costs from chronic disease inequities will become unsustainable. Broadening
health policies designed to improve delivery of preventive services for minority populations may help
reduce substantial medical costs caused by inequities in health care, resulting in a return on
investment.
Policies
Chronic disease is a population level issue that requires population health level efforts and national
and state level public policy to effectively prevent, rather than individual level efforts. The United
States currently employs many public health policy efforts aligned with the preventive health efforts
discussed above. For instance, the Centers for Disease Control and Prevention support initiatives such
as Health in All Policies and HI-5 (Health Impact in 5 Years), collaborative efforts that aim to
consider prevention across sectors[131] and address social determinants of health as a method of
primary prevention for chronic disease.[132] Specific examples of programs targeting vaccination and
obesity prevention in childhood are discussed in the sections to follow.
Obesity
Policies that address the obesity epidemic should be proactive and far-reaching, including a variety of
stakeholders both in healthcare and in other sectors. Recommendations from the Institute of
Medicine in 2012 suggest that “…concerted action be taken across and within five environments
(physical activity (PA), food and beverage, marketing and messaging, healthcare and worksites, and
schools) and all sectors of society (including government, business and industry, schools, child care,
urban planning, recreation, transportation, media, public health, agriculture, communities, and
home) in order for obesity prevention efforts to truly be successful.”[133]
There are dozens of current policies acting at either (or all of) the federal, state, local and school
levels. Most states employ a physical education requirement of 150 minutes of physical education per
week at school, a policy of the National Association of Sport and Physical Education. In some cities,
including Philadelphia, a sugary food tax is employed. This is a part of an amendment to Title 19 of
the Philadelphia Code, “Finance, Taxes and Collections”; Chapter 19-4100, “Sugar-Sweetened
Beverage Tax, that was approved 2016, which establishes an excise tax of $0.015 per fluid ounce on
distributors of beverages sweetened with both caloric and non-caloric sweeteners.[134] Distributors
are required to file a return with the department, and the department can collect taxes, among other
responsibilities.
These policies can be a source of tax credits. For example, under the Philadelphia policy, businesses
can apply for tax credits with the revenue department on a first-come, first-served basis. This applies
until the total amount of credits for a particular year reaches one million dollars.[135]
Recently, advertisements for food and beverages directed at children have received much attention.
The Children's Food and Beverage Advertising Initiative (CFBAI) is a self-regulatory program of the
food industry. Each participating company makes a public pledge that details its commitment to
advertise only foods that meet certain nutritional criteria to children under 12 years old.[136] This is a
self-regulated program with policies written by the Council of Better Business Bureaus. The Robert
Wood Johnson Foundation funded research to test the efficacy of the CFBAI. The results showed
progress in terms of decreased advertising of food products that target children and adolescents.[137]
Childhood immunization policies
Despite nationwide controversies over childhood vaccination and immunization, there are policies
and programs at the federal, state, local and school levels outlining vaccination requirements. All
states require children to be vaccinated against certain communicable diseases as a condition for
school attendance. However, currently 18 states allow exemptions for “philosophical or moral
reasons.” Diseases for which vaccinations form part of the standard ACIP vaccination schedule are
diphtheria tetanus pertussis (whooping cough), poliomyelitis (polio), measles, mumps, rubella,
haemophilus influenzae type b, hepatitis B, influenza, and pneumococcal infections.[138] These
schedules can be viewed on the CDC website.[139]
The CDC website describes a federally funded program, Vaccines for Children (VFC), which provides
vaccines at no cost to children who might not otherwise be vaccinated because of inability to pay.
Additionally, the Advisory Committee on Immunization Practices (ACIP)[140] is an expert vaccination
advisory board that informs vaccination policy and guides on-going recommendations to the CDC,
incorporating the most up-to-date cost-effectiveness and risk-benefit evidence in its
recommendations.
See also
American Board of Preventive Medicine
American Journal of Preventive Medicine
American Osteopathic Board of Preventive Medicine
Mental illness prevention

Public health
Pre-exposure prophylaxis
Preventive Medicine (journal)
Primary Health Care
Treatment as prevention
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External links
United States Preventive Services Task Force (USPSTF) (http://www.uspreventiveservicestaskfor
ce.org/)
Canadian Task Force on Preventive Health Care (CTFPHC) (https://canadiantaskforce.ca/)
European Centre for Disease Prevention and Control (ECDC) (http://www.ecdc.europa.eu/en/Pag
es/home.aspx)
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Each year, millions of people die of preventable deaths. A 2004

Primal and primordial prevention

majority of residents lacking transportation.[29]

Leading causes of preventable death

Leading causes of preventable deaths in the United States in the year

Leading causes of preventable death worldwide as of the year 2001[33]

Sexually transmitted infections

Sexually transmitted infections (STIs), such as syphilis and HIV,

Malaria prevention using genetic modiﬁcation

Lung cancer is the leading cause of cancer-related deaths in the

Skin cancer is the most common cancer in the United States.[49]

The Centers for Disease Control and Prevention (CDC)

Health disparities and barriers to accessing care

Economics of lifestyle-based prevention

Cost-effectiveness of childhood obesity interventions

Economics of US preventive care

Clinical preventive services & programs

Economics for investment

The Affordable Care Act and preventive healthcare

Evaluating incremental beneﬁts

Mortality from modifiable risk factors

Health capital theory

Quality adjusted life years

Childhood immunization policies

Mental illness prevention

16. Gillman MW (2015). "Primordial Prevention of Cardiovascular Disease" (https://www.ncbi.nlm.nih.

31. "It's a Market on a Bus" (https://web.archive.org/web/20151120001336/http://www.wilder.org/Progr

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