PATIENT AND PHYSICIAN PRIORITIZATION OF PREVENTIVE SERVICES DURING ANNUAL CHECK UPS

Purpose: Limited time and competing demands force primary care physicians and patients to prioritize among evidence-based preventive health services. We describe how preventive services are prioritized relative to established cost-effectiveness (CE) rankings during annual check ups.

Method: Automated claims and a pre-visit survey were used to identify which evidence-based screening and counseling services patients were due for at the time of an annual check up. Participating physicians are internal or family medicine physicians practicing in a salaried medical group in southeast Michigan. Eligible patients are insured, ages 50-80, and due for colorectal cancer screening. Trained observers documented preventive services discussed, who initiated the topic, and recommendation/delivery during the visit. Using the first 296 visits observed, we evaluated the rate of discussion, topic raising, and service recommendation/delivery among patients due for service. Rates are evaluated overall and by using CE rankings that range from 1 to 5 (least to most cost effective) as published by Maciosek et al (2006).

Result: Patient participants are on average 59 years old, 66% female and 68% White. Among evidence-based services, colorectal cancer (96%), smoking (95%), and cervical cancer (93%) were most likely to be discussed, while mental health was least likely (50%). Most discussions were physician initiated, but patients were relatively more likely to raise osteoporosis, mental health, obesity, and diet (31-38%), all of which have relatively low CE rankings compared to other services. Topics most often raised by physicians included both lower (breast cancer screening) and higher CE rank (hypertension and colorectal cancer screening). Physicians most often recommended hypertension screening (96%), colorectal cancer screening (89%), and breast cancer screening (88%) and were least likely to counsel for alcohol (5%), mental health (7%) and obesity (16%). Two of the most cost-effective services, tobacco cessation and alcohol counseling, were delivered to a minority of patients who reported smoking (40%) or problem drinking (5%).

Conclusion: Primary care physicians and patients often discuss cost-effective preventive services during annual check ups. However, some of the least cost-effective topics are more likely to be raised by patients and are less likely to result in physician recommendations or service delivery. Physicians prioritize screening services over counseling services, in particular missing opportunities to deliver counseling for tobacco cessation and problem drinking despite their high CE rankings.