New Recommendations Aim to Reduce Disparities in Clinical Preventive Services

By Will Boggs MD

January 14, 2020

NEW YORK (Reuters Health) - A workshop convened by the National Institutes of Health (NIH) offers recommendations for new research to improve delivery of preventive services and reduce disparities across 10 preventable conditions.

"No one should die in the U.S. because they lacked access to an effective preventive test," Dr. Timothy S. Carey from University of North Carolina at Chapel Hill told Reuters Health by email. "While we currently have some tools to improve rates of preventive services in populations at risk for underuse, we need to learn more regarding how to more efficiently and effectively reduce the current disparities."

Armed with a systematic evidence review that assessed the literature and methods used to evaluate interventions for reducing disparities in preventive services, Dr. Carey and colleagues considered five key question topics. Ultimately they issued 26 recommendations.

As reported in Annals of Internal Medicine, three themes emerged: the need for community engagement and systems approaches; the importance of integration of services and new delivery models; and the need for innovative methods.

Future research should develop standard definitions and metrics of provider barriers and impediments and assess their impact on the adoption and promotion of evidence-based preventive services specific to at-risk groups. This should include assessment of new training approaches for reducing bias related to patient interactions around preventive services.

Research should also test organizational and management interventions for enabling clinicians and practice managers to implement disparity-reducing interventions.

Health intervention technology studies should be fully embedded in the healthcare system to facilitate testing of intervention effectiveness, which should include monitoring new models for unintended consequences.

Research should include testing of models for identifying and reaching out to people seeking care who are in need of clinical preventive services but have not been engaged yet; determining whether the success in improving use of preventive services for cancer and at-risk populations can be replicated for other conditions; and investigating how to sustain interinstitutional partnerships focused on increasing the use of preventive services.

"Physicians should work with colleagues and health system administrators to assess their current rates of completion of preventive tests in at-risk populations, then implement and evaluate system interventions to reduce disparities in effective preventive care," Dr. Carey concluded. "While some of the recommended new research might be supported by NIH, AHRQ (Agency for Healthcare Research and Quality), PCORI (Patient-Centered Outcomes Research Institute), and other entities, we hope providers will work with colleagues to test these recommendations and determine the best methods to reduce disparities in care use. We need learning health systems."

Dr. Heidi D. Nelson from Oregon Health and Science University, Portland, who co-authored the systematic review used by the workshop, said by email, "Patient navigation, telephone calls and prompts, and reminders involving lay health workers increased cancer screening in populations adversely affected by disparities. These types of high-touch, low-tech interventions could be implemented now while other types of interventions are being developed and evaluated, such as decision aids and health information technology."

The NIH Pathways to Prevention Workshop was tasked to define a research agenda, not advise clinical practice, she said, but still, "findings of the evidence review may inform practice by summarizing results of current studies relevant to clinicians."

Dr. Michael Bretthauer from University of Oslo and Oslo University Hospital, Norway, who co-authored an editorial related to this report, told Reuters Health by email, "Access to preventive services is important. But participation is up to each individual, and dispassionate information and advice about absolute benefits, harms, and burdens is our (physicians') task. It is not to nudge people into it."

The editorial points out that "reducing disparity and improving net benefit in a population's health may require not only increasing participation in preventive services by minority groups, but also reducing participation among majority populations. Future work should consider both measures."

Dr. Kevin Fiscella from University of Rochester Medical Center, New York, who recently reviewed racial and ethnic disparities in the quality of healthcare, told Reuters Health by email, "I wish the report had emphasized 'elephant in the room,' i.e., current payment systems foster inequities in preventive services through misalignment between well-known patient needs/barriers (direct or indirect costs, knowledge, attitudes, transportation, fear, mistrust, perceived bias, etc.) and the resources necessary to address those needs."

"This misalignment between resources and needs is often worse in safety practices and hospital systems," he said. "The research recommendations in the report could inform optimal use of resources and make the case for innovations, such patient advisory groups, tailored self-management support, and/or patient navigation."

"Hopefully, enactment of the recommendations in the report will foster recognition that human relationships are the foundation for health equity in preventive services," Dr. Fiscella concluded.

SOURCE: and Annals of Internal Medicine, online January 13, 2020.