To the Editor: In the Perspective article by Cohen et al. (Feb.14 issue),1 a narrow construction of what constitutes preventionleads to erroneous conclusions about its potential impact andcost-effectiveness. The authors do not address preventive interventionsthat occur outside the doctor's office. These include basicpublic health services and many other policies that bear directlyon health (e.g., seat-belt laws and smoke-free policies). Healthgains achieved through population-based approaches often exceedthose that can be accomplished clinically, and these approachesare often cost-saving or highly cost-effective.2
Even if one considers only prevention in clinical settings,many high-value services are substantially underutilized. Forexample, less than 50% of the target population receives smoking-cessationservices, counseling about aspirin use, colorectal-cancer screening,and influenza vaccines. Increasing use of these four servicesto 90% would save more than 100,000 lives annually.3
Policymakers should support investment in prevention for theright reasons — namely, to improve health at an acceptablecost, even if the services will not reduce overall spending.If reduced spending is the goal, then policymakers should discourageuse of low-value services, both therapeutic and preventive.
Jonathan E. Fielding, M.D., M.P.H. Los Angeles County Department of Public Health Los Angeles, CA 90012
Corinne G. Husten, M.D., M.P.H. Jordan H. Richland, M.P.H., M.P.A. Partnership for Prevention Washington, DC 20036 chusten{at}prevent.org
References
Cohen JT, Neumann PJ, Weinstein MC. Does preventive care save money? Health economics and the presidential candidates. N Engl J Med 2008;358:661-663. [Free Full Text]
Task Force on Community Preventive Services. The guide to community preventive services: what works to promote health? New York: Oxford University Press, 2005.
Preventive care: a national profile on use, disparities, and health benefits. Washington, DC: Partnership for Prevention, 2007.
The authors reply: Fielding and colleagues correctly highlightcommunity-based interventions as important preventive strategiesto evaluate, but they fail to note that our analysis of 1500comparisons described in 599 articles drawn from the Tufts MedicalCenter Cost-Effectiveness Analysis Registry (www.cearegistry.org)did in fact include a number of community-based interventions.Like clinical preventive services, nonclinical interventionsare sometimes expensive (e.g., a ban on cell-phone use whilepeople are driving, which costs $380,000 per quality-adjustedlife-year, or QALY1) and sometimes cost-saving (e.g., folicacid fortification of grains2 and condom distribution3). Otherinterventions cost the health care system more money than theysave but generally deliver good value,4 meaning that they costless than commonly recognized benchmarks for cost per QALY.5
We also agree that, as we stated in our article, "In additionto determining which preventive measures and treatments aremost efficient, it will be necessary to identify those thatare not yet fully deployed and those that could serve a largepopulation and bring about substantial aggregate improvementsin health at an acceptable cost."
Joshua T. Cohen, Ph.D. Peter J. Neumann, Sc.D. Tufts Medical Center Boston, MA 02111
Milton C. Weinstein, Ph.D. Harvard School of Public Health Boston, MA 02115
References
Cohen JT, Graham JD. A revised economic analysis of restrictions on the use of cell phones while driving. Risk Anal 2003;23:5-17. [CrossRef][Web of Science][Medline]
Tice JA, Ross E, Coxson PG, et al. Cost-effectiveness of vitamin therapy to lower plasma homocysteine levels for the prevention of coronary heart disease: effect of grain fortification and beyond. JAMA 2001;286:936-943. [Free Full Text]
Bedimo AL, Pinkerton SD, Cohen DA, Gray B, Farley TA. Condom distribution: a cost-utility analysis. Int J STD AIDS 2002;13:384-392. [Free Full Text]
Tengs TO, Osgood ND, Chen LL. The cost-effectiveness of intensive national school-based anti-tobacco education: results from the tobacco policy model. Prev Med 2001;33:558-570. [CrossRef][Web of Science][Medline]
Weinstein MC. How much are Americans willing to pay for a quality-adjusted life year? Med Care 2008;46:343-345. [Web of Science][Medline]
Hawkins, J. D.
(2010). Broadening Understanding of the Long-term Effects of Risk- and Protection-Focused Prevention on the Public Health: Lessons From Nurse-Family Partnerships. Arch Pediatr Adolesc Med
164: 92-94
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