Preventive care: What is the physician’s role in improving compliance?

As of 2015, only 8% of US adults aged 35 years and older have received all of the high-priority, appropriate clinical preventive services recommended to them, according to the results of a study published in Health Affairs. Furthermore, approximately 5% of adults did not receive any such services.

If it’s better to prevent disease than treat it, then why are so few adults receiving preventive care?

The answer is likely multifactorial, with physicians and patients both playing a role. Nevertheless, it’s a moral imperative for physicians to make time to provide preventive healthcare counseling to patients. Fortunately, it is possible to manage chronic disease and provide your patients with appropriate preventive health counseling at the same time. Read on below for more details.

US Preventive Services Task Force (USPSTF) ‘A’ grade recommendations

The following table contains USPSTF “A” grade recommendations, which indicate that there is high certainty that the net benefit is substantial. This table is adapted from the one provided by the USPSTF website. These recommendations can be considered the “biggies.”

Topic	USPSTF recommendations	Release date of current recommendation
Bacteriuria screening: Pregnant women	Screening for asymptomatic bacteriuria with urine culture in pregnant women at 12 to 16 weeks' gestation or at the first prenatal visit, if later.	July 2008
Blood pressure screening: Adults	Screening for high blood pressure in adults aged 18 years or older. The USPSTF recommends obtaining measurements outside of the clinical setting for diagnostic confirmation before starting treatment.	October 2015
Cervical cancer screening	Screening for cervical cancer every 3 years with cervical cytology alone in women aged 21-29 years. For women aged 30-65 years, the USPSTF recommends screening every 3 years with cervical cytology alone, every 5 years with high-risk human papillomavirus (hrHPV) testing alone, or every 5 years with hrHPV testing in combination with cytology (co-testing).	August 2018
Colorectal cancer screening	Screening for colorectal cancer starting at age 50 years and continuing until age 75 years.	June 2016
Folic acid supplementation	All women who are planning or capable of pregnancy should take a daily supplement containing 0.4 to 0.8 mg (400 to 800 µg) of folic acid.	January 2017
Gonorrhea prophylactic medication: Newborns	Prophylactic ocular topical medication for all newborns to prevent gonococcal ophthalmia neonatorum.	January 2019
Hemoglobinopathies screening: Newborns	Screening for sickle cell disease in newborns.	September 2007
Hepatitis B screening: Pregnant women	Screening for hepatitis B virus infection in pregnant women at their first prenatal visit.	July 2019
HIV preexposure prophylaxis for the prevention of HIV infection	Clinicians should offer preexposure prophylaxis (PrEP) with effective antiretroviral therapy to individuals at high risk of HIV infection.	June 2019
HIV screening: Adolescents and adults aged 15-65 years	Clinicians should screen for HIV infection in adolescents and adults aged 15-65 years. Younger adolescents and older adults who are at increased risk of infection should also be screened.	June 2019
HIV screening: Pregnant women	Clinicians should screen for HIV infection in all pregnant persons, including those who present in labor, or at delivery whose HIV status is unknown.	June 2019
Hypothyroidism screening: Newborns	Screening for congenital hypothyroidism in newborns.	March 2008
Rh incompatibility screening: First pregnancy visit	Rh (D) blood typing and antibody testing for all pregnant women during their first visit for pregnancy-related care is strongly encouraged.	February 2004
Syphilis screening: Nonpregnant persons	Screening for syphilis infection in persons who are at increased risk for infection.	June 2016
Syphilis screening: Pregnant women	Early screening for syphilis infection in all pregnant women.	September 2018
Tobacco use counseling and interventions: Nonpregnant adults	Clinicians should ask all adults about tobacco use, advise them to stop using tobacco, and provide behavioral interventions and FDA–approved pharmacotherapy for cessation to adults who use tobacco.	September 2015
Tobacco use counseling: Pregnant women	Clinicians should ask all pregnant women about tobacco use, advise them to stop using tobacco, and provide behavioral interventions for cessation to pregnant women who use tobacco.	September 2015

Patient compliance

As noted, patients do play a role in low rates of preventive healthcare services.

In the aforementioned study (N = 2,186), the researchers found that although only a small percentage of adult patients (8%) received all of the high-priority preventive healthcare service recommended to them, more than 20% received nearly all (over 75%) of these preventive services—indicating that comprehensive preventative healthcare is, indeed, realistic and achievable.

Moreover, men were more likely to have received 0% to 25% of all services compared with women (21.9% vs 11.3%, respectively; P < 0.001). The most common preventive service that all study participants received was blood pressure screening, with close to 90% compliance; the least common was herpes zoster vaccination, with less than 40% compliance.

Historically, patient compliance with preventive services has been suboptimal, and often associated with socioeconomic status, race, and access to care. Experts have cited five main reasons for patient failure to schedule and receive recommended preventive testing/screenings:

1. Patients assume the services are expensive.
2. Patients don’t know which preventive services they need.
3. Patients forget to schedule routine preventive care appointments.
4. Patients don’t know whom to contact to make these appointments.
5. Preventive care is not a priority for patients.

Role of the physician

Although patients do contribute to the lower rates of preventive healthcare services, physicians also play a part, and must focus on what they can do to improve the status quo.

Effective preventive care services may include educating and motivating patients with respect to healthy lifestyle choices; assisting patients by understanding their needs, preferences, and readiness for change; and counseling on important preventive care measures

Lack of preventive health services is widely documented. For instance, only half of smokers report receiving meaningful smoking cessation counseling from their physicians. Furthermore, less than one-third of patients have received blood stool testing in the past 2 years.

Unsurprisingly, the most likely reason why physicians don’t effectively counsel patients on preventive care is lack of time. Experts estimate that it would take a physician 7.4 additional working hours each day to hit all the USPSTF guidelines. Understandably, physicians have to omit certain counseling to get through their workload.

Even with limited time, however, researchers have indicated that physicians still manage to hit many of the USPSTF “A” grade recommendations, often at the expense of glossing over “B” grade recommendations. Nevertheless, there are plenty of important B grade interventions, including counseling teens on tobacco cessation, skin cancer counseling, and obesity counseling, which should be considered. Moreover, physicians often spend time counseling on preventive health issues of lower priority.

Moral imperative

According to the American Medical Association (AMA):

“Medicine and public health share an ethical foundation stemming from the essential and direct role that health plays in human flourishing. While a physician’s role tends to focus on diagnosing and treating illness once it occurs, physicians also have a professional commitment to prevent disease and promote health and well-being for their patients and the community.”

The AMA goes on to point out that, although primary care physicians provide the majority of preventive health counseling, specialists can pitch in as well—especially if the patient is a long-standing one or the advice closely relates to the condition being treated. Furthermore, health promotion should be patient-centered and promote trust while recognizing the patient’s self-directed roles in keeping healthy.

Here is some specific advice for individual physicians committed to the health of patients and the public, per the AMA:

• Stay current with preventive care guidelines that apply to patients, and verify that the interventions are recommended and evidence based (eg, USPSTF or American Cancer Society).
• Take a personalized approach, and educate patients concerning modifiable risk factors that are relevant to the patient.
• Promote appropriate vaccinations and screenings.
• Discuss circumstances that make it difficult to manage chronic conditions or maintain a healthy lifestyle, including transportation, work, home, and social support issues.
• Brainstorm with the patient about recommendations that will likely be effective.
• Point the patient to preventive health resources available to the public.
• Model healthy behaviors for your patients.
• Consider the health of the community and contact the public health authorities as needed.

Of note, when pressed for time, consider having a nurse or health educator address more of the counseling, while you focus on the challenges of chronic care disease management. Although this team-based approach may appear fragmented or poorly coordinated to the patient, researchers have suggested that quality of care and patient satisfaction are typically higher with this approach vs the traditional solo physician model.