Physicians Overlook Some Preventive Services Tied to Longer Life

By Lisa Rapaport

August 07, 2020

(Reuters Health) - Most physicians prioritize which preventive services to discuss with patients based on time constraints and assumptions about which interventions improve quality or length of life, and the majority of them don't prioritize lifestyle changes like diet and exercise, a new study suggests.

Researchers examined survey data from 137 primary care physicians who were asked how and to what extent they prioritize preventive services in clinical practice, how they would set preventive service priorities for two hypothetical patients, and how they would prioritize preventive services for 20 minute versus 40 minute visits.

Most physicians prioritized based on the potential for interventions to improve quality of life (mean score 4.56) or duration of life (mean score 4.53).

"There are lots of guidelines, but these are organized around evidence for or against a specific intervention and they just say do it or don't do it," said study co-author Dr. Michael Rothberg, director of the Center for Value-Based Care Research at Cleveland Clinic in Ohio.

"They don't help you prioritize if you don't have time (or the patient doesn't want) to do them all," Dr. Rothberg said by email.

Researchers used a mathematical model to compare how closely physicians' priorities for preventive services for two hypothetical patients in the survey matched up with services most likely to improve life expectancy.

One hypothetical patient was a 50-year-old white woman with type 2 diabetes, obesity, hypertension, hyperlipidemia, a 30-pack-year history of smoking, and a family history of breast cancer. The top priorities physicians set for this patient were smoking cessation, hypertension control, and glycemic control.

Given a 40-minute visit for this patient, physicians said they would discuss a median of 11 preventive services; they would only prioritize a median of 5 in the shorter 20-minute appointment.

The second hypothetical patient was a 45-year-old Black man with obesity, hyperlipidemia, hypertension, a family history of colon cancer, and a 30-pack-year history of smoking. For this patient, physicians' top three priorities were smoking cessation, hypertension control, and colorectal cancer screening.

For this man, physicians said they would discuss a median of 9 preventive services in a 40 minute visit, and only prioritize a median of 4 if they had to do a 20 minute visit.

Only 48 physicians (35%) included weight loss, diet or exercise discussions among their top three priorities for either patient, researchers report in JAMA Network Open. However, these three things were among the preventive services most likely to improve life expectancy under the mathematical model researchers used to determine the most beneficial services.

"Personally, I think most patients would be better off if we spent more time focusing on the causes of their illness--it's a lot more effective to get someone to quit smoking when they are young than to treat the COPD, heart disease and cancer that follow," Dr. Rothberg said. "If we spent more time on the lifestyle aspects, we might not need to spend as much time on the other care."

One limitation of the study is that it had a 57% response rate for the survey. Results also may have limited generalizability because participants all worked in one health system.

The snapshot of how physicians would handle a single encounter with a hypothetical patient also may not capture how care evolves over time with subsequent visits, said Dr. Erin LeBlanc, a senior investigator at Kaiser Permanente Center for Health Research Northwest in Portland, Oregon.

"Physicians may prefer to wait to tackle the more challenging and time-consuming conversation about weight loss, diet, and exercise to a later visit when they have developed a stronger connection with a patient," Dr. LeBlanc, who wasn't involved in the study, said by email. "Preventive care works best when it occurs over time in a setting of mutual trust between a patient and physician."

SOURCE: JAMA Network Open, online July 27, 2020.