Chapter Outline
Primary, Secondary, and Tertiary Prevention
United States Preventive Services Task Force
Influencing Health Behavior Changes
In 2013, the Unites States spent $2.9 trillion on health care, or $9255 per person. The amount spent on health care is expected to increase at an average rate of 5.8% per year. The United States spends almost one and a half times as much on health care as any other country. Yet the United States has the highest infant mortality rate of industrialized countries, highest prevalence of overweight children, and highest admission rate for asthma and ranks 43rd for life expectancy. This shows that the United States has one of the most inefficient health care systems worldwide ( Fig. 13.1 ).
The high cost of health care is in part due to the traditional needs-based, medical intervention system in our country. That is, when someone becomes ill, she or he accesses health services, which often cannot treat the issue but only delays further morbidity or mortality. Much of the treatment that is provided could be avoided if preventive medicine was performed with a population or public health approach. Intervening at the population level early on results in less individual morbidity and mortality, also resulting in lower health care expenditures and a healthier population.
The concept of population health has gained attention over the years. The overall purpose of population health is to maintain and improve the health of an entire population by reducing disparities and impacting the determinants of health ( Fig. 13.2 ). This includes focusing on health indicators such as social, economic, and physical environments that influence individuals, communities, and populations of people. The health factors that affect population health include physical environment (air and water quality, housing, transit), social and economic (employment status, education status, income), clinical care (access to care, quality of care, genetics (predispositions), and health behaviors (tobacco use, diet and exercise, and alcohol and drug use). From a population health perspective, each of these determinants needs to be considered in order to have a significant impact on health outcomes.
The Prevention Institute, the California Endowment, and the Urban Institute reviewed the role prevention plays in health care costs and were able to identify key issues associated with health and cost. Most of the illnesses that are associated with the highest health care expenditures are in part preventable ( Fig. 13.3 and Table 13.1 ). The key issues include resources that are being used to influence health are not used efficiently or effectively, a small reduction in disease incidence can lead to substantial savings overall (e.g., a 5% reduction in heart disease can lead to an estimated $974,078,000 savings), effective prevention strategies have already led to a reduction in overall costs, and a reduction in end-of-life care can reduce morbidities.
| Disease | Number of Deaths Annually |
|---|---|
| Heart disease | 7.4 million |
| Cerebrovascular accidents | 6.7 million |
| Diabetes | 1.5 million |
| Trauma | 1.3 million |
| Hypertension | 1.1 million |
With the ever expanding opportunities for physician assistants (PA), it is important that PAs recognize their role in population health. PAs need to help transition the focus of medicine to a public health or population health perspective that emphasizes preventive medicine, identifies and corrects disparities, integrates behavior and social sciences, and aims to increase the health of the population as a whole. PAs have the opportunity to engage their communities in identifying disparities that are affecting their health and address these through community involvement with an emphasis on primary prevention.
Primary, Secondary, and Tertiary Prevention
There are three approaches to prevention: primary, secondary, and tertiary. The primary approach focuses on preventing disease before it develops; tertiary prevention is directed at managing established disease in someone and avoiding further complications (much of how we currently manage patients). To decrease health care expense and increase population and individual health, all three of these prevention methods should be used. However, the emphasis needs to shift from tertiary to primary prevention.
The goal of primary prevention is to impact health outcomes before the onset of disease or injury. This approach classically addresses populations, such as a nationwide campaign to address obesity or targeted at-risk populations, for instance, providing flu vaccines. Because of reaching a large number of individuals, primary prevention can have a substantial impact on economic benefits and is extremely cost effective. Primary prevention can require changes on individual levels as well as policy levels. For example, whereas tooth brushing and flossing are individual prevention measures, adding fluoride to water is a policy prevention change.
Secondary prevention implies that for the specific disease, primary prevention has not been sufficient. The goal of secondary prevention is to identify a disease early in its process in order to maximize the success of treatment and decrease the incidence of morbidity or mortality related to that disease (in other words, identifying a disease while it is still asymptomatic). This includes the routine, recommended screening for cancer, diabetes, and hypertension. In these cases, patients are often without symptoms, and the diagnosis is made through screening methods.
Tertiary prevention is what has traditionally been seen in medicine when a patient presents with symptoms and a disease process is identified, but it is too advanced and a definitive cure is no longer an option. For these patients, the goal of tertiary prevention is to maximize the outcomes and prevent further morbidity from the disease process. An example of this is a patient who presents to the emergency department with chest pain. After a thorough workup, it is determined that the patient is having a myocardial infarction. The damage that has been done to the heart cannot be reversed; however, with appropriate cardiac therapy and rehabilitation, the patient would be able to maximize his or her cardiac output and prevent further morbidity and mortality associated with the myocardial infarction.
Most patients require a combination of prevention approaches; however, it is the PA’s responsibility to recognize common secondary and tertiary issues within his or her practice and consider primary community intervention strategies to address these issues and maximize community health. Often the intervention includes increasing access to health care, community education, and community empowerment to shift the focus from tertiary prevention to primary prevention ( Table 13.2 ).
Lydia, an obstetric/gynecologic PA, is concerned with the prevalence of cervical abnormalities present in her practice. This prevalence has led to many costly and uncomfortable procedures for her patients to better monitor cervical changes. Lydia knows that currently there is no cure for human papillomavirus (HPV), which is strongly correlated with cervical cancer. She decides that her efforts are not enough. Lydia’s practice is located next to a major university campus. Although she sees a diverse population of patients, she has a significant portion of university students. Lydia decided to survey the university students to assess what percentage of students have received the HPV vaccine, the only known way to prevent cervical cancer. She found that the majority of the students had not received the three-dose series of the vaccine. In response to her assessment, Lydia established an HPV vaccination clinic on the university campus. Through this clinic, she was able to provide on-campus education about HPV and cervical cancer and offer the vaccine at no cost to all university students and employees who were eligible for the vaccine. Her vaccination clinic was able to increase the vaccination rate of university students by 60%.
Identify the levels of prevention:
Primary: HPV vaccination clinic
Secondary: routine Pap smears
Tertiary: treating and monitoring those already diagnosed with cervical abnormalities
Identify the impact this will have on the community:
Decreasing the prevalence of HPV in an at-risk university population decreases health care expenditures and morbidity on future cervical abnormalities. Lydia addressed the lack of education about HPV, increased access to university students and faculty by putting the clinic on campus, and eliminated the cost barrier. By addressing these determinants, she was able to impact her community’s health.
| Type of Prevention | Examples of Prevention |
|---|---|
| Primary | Daily recommended diet and exercise Wearing a helmet when bike riding Vaccines Teeth brushing and flossing Hand washing Smoking or alcohol cessation Prenatal vitamins Condom use |
| Secondary | Recommended screenings: Pap, mammography, prostate specific antigen, colonoscopy, DEXA scan, blood pressure, glucose, cholesterol Prenatal screenings HIV screening |
| Tertiary | Improving glucose control in patients with diabetes Rehabilitation after myocardial infarction or injury Providing counseling to victims of rape or PTSD |
Immunization Strategies
Immunization plays a pivotal role in public health, helping to control and eliminate once prevalent communicable diseases that cause illness, hospitalization, morbidity, and mortality for infants, children, and adults. A vaccine works by mimicking a natural disease without acquiring the actual disease in order to stimulate the immune system to combat the natural disease in the case of exposure. Fig. 13.4 illustrates that as the use of vaccination increases, the number of cases of the disease decreases in the population, and oppositely, when vaccinations decrease, there is a rise in the incidence of disease in the population.
Fig. 13.5 illustrates the importance of vaccinating the majority of people in the population and worldwide. Lower numbers of vaccinated individuals lead to continued spread of a disease; however, if most people in the population are vaccinated against a disease, fewer individuals will contract the disease and spread the disease to others. Similarly, unless a disease is completely eliminated, as in the case of smallpox, immunization of the majority of the population must continue, or the disease will reappear with its health-related consequences.
