Skip to main content
Download PDF

Priorities among effective clinical preventive services in British Columbia, Canada

BMC Health Services Research volume 22, Article number: 564 (2022) Cite this article

Abstract

Background

Despite the long-standing experience of rating the evidence for clinical preventive services, the delivery of effective clinical preventive services in Canada and elsewhere is less than optimal. We outline an approach used in British Columbia to assist in determining which effective clinical preventive services are worth doing.

Methods

We calculated the clinically preventable burden and cost-effectiveness for 28 clinical preventive services that received a ‘strong or conditional (weak) recommendation for’ by the Canadian Task Force on Preventive Health Care or an ‘A’ or ‘B’ rating by the United States Preventive Services Task Force. Clinically preventable burden is the total quality adjusted life years that could be gained if the clinical preventive services were delivered at recommended intervals to a British Columbia birth cohort of 40,000 individuals over the years of life that the service is recommended. Cost-effectiveness is the net cost per quality adjusted life year gained.

Results

Clinical preventive services with the highest population impact and best value for money include services that address tobacco use in adolescents and adults, exclusive breastfeeding, and screening for hypertension and other cardiovascular disease risk factors followed by appropriate pharmaceutical treatment. In addition, alcohol misuse screening and brief counseling, one-time screening for hepatitis C virus infection in British Columbia adults born between 1945 and 1965, and screening for type 2 diabetes approach these high-value clinical preventive services.

Conclusions

These results enable policy makers to say with some confidence what preventive manoeuvres are worth doing but further work is required to determine the best way to deliver these services to all those eligible and to establish what supportive services are required. After all, if a clinical preventive service is worth doing, it is worth doing well.

Peer Review reports

Background

The Canadian Task Force on the Periodic Health Exam (later re-named the Canadian Task Force on Preventive Health Care - CTFPHC) began to review and rate clinical preventive services (CPS) in 1976 [1], and the US Preventive Services Task Force (USPSTF) took up and further developed this work starting in 1984 [2]. Despite the long-standing experience of rating the evidence for CPS, the delivery of effective CPS in Canada and elsewhere is less than optimal [3,4,5]. Suggested reasons for this include health care providers’ lack of time, as well as the patient’s inability to find a provider and the lack of coordination across providers and settings [6, 7]. Yarnall estimated that 7.4 h of every primary care physician’s working day would be required to fully satisfy all the USPSTF ‘A’ and ‘B’ recommendations, based on a patient panel of 2500 with an age and sex distribution similar to that of the US population [8]. An absence of policy and supportive management and payment systems is another factor in health systems focused on acute care [9].

The optimal delivery of CPS has important benefits for the health of the population. One study estimated that between 75,000 and 140,000 deaths could be avoided annually in the United States by increasing the use of nine CPS [10] while another estimated a saving of 2.6 million quality-adjusted life years in a US birth cohort of 4 million if utilization rates increased from current levels to 90% for 20 CPS [11].

The HealthPartners Institute in the US has attempted to reconcile the value of CPS with a provider’s lack of time, by prioritising effective CPS [11,12,13,14]. They note that the greatest population health improvement in the US could be gained by prioritizing CPS that address tobacco use, obesity-related behaviours and alcohol misuse [11].

Faced with this information and the lack of provincial policy on clinical preventive services in BC, the Ministry of Health established the Clinical Prevention Policy Review (CPPR) in January of 2007. The review process involved establishing a broad-based CPPR Expert Advisory Committee (the Committee), including experts from the US, the CTFPHC, the BC Medical Association (now Doctors of BC), the Canadian College of Family Physicians and others; Dr. Hans Krueger was hired as the lead consultant for the Committee.

The review asked three seemingly simple questions: What preventive manoeuvres are worth doing, what is the best way to deliver what is worth doing, and what systems need to be put in place to support delivery? While the technical reports [15] (and this article) focus primarily on the first question, the main report [9] also discussed the second and third questions, and these are further discussed towards the end of this article.

We prioritize 28 effective CPS in British Columbia, Canada using an adapted version of the approach developed by HealthPartners Institute [12]. The policy goal is to guide decision-making by the BC Ministry of Health in initiating or expanding CPS within the province.

Methods

Definitions

A CPS is defined as any maneuver(s) pertaining to primary and early secondary prevention (i.e., immunization, screening, counselling and preventive medication/device) offered to the general (asymptomatic) population based on age, sex and risk factors for disease and delivered on a one-provider-to-one-client basis, with two qualifications: (i) the provider could work as a member of a care team or as part of a system tasked with providing, for instance, a screening service; and (ii) the client could belong to a small group (e.g. a family, a group of smokers) that is jointly benefiting from the service.

A clinically preventable burden (CPB) is defined as the total quality adjusted life years (QALYs) that could be gained if the CPS were delivered at recommended intervals to a BC birth cohort of 40,000 individuals (the approximate number of annual births in BC) over the years of life that the service is recommended. Cost-effectiveness (CE) is defined as the net cost per QALY gained.

Selection of clinical preventive services for review

In 2006, the HealthPartners Institute published a study which ranked 25 evidence-based CPS on a scale of 2 (low priority) to 10 (high priority) [14]. Of the 25 CPS, 15 received a rank of 6 or higher. In 2008, we requested and received Excel-based models for 10 of the 15 CPS. The 10 models were adjusted to incorporate available BC-specific data in calculating CPB and CE. In the adjusted models, we also used the difference between no service and the best utilization rate for that CPS observed in high-income countries (see Table 1), rather than the 90% utilization rate assumed in the HealthPartners modelling [11]. This approach was chosen to better reflect actual benefits and costs associated with potentially achievable utilization rates.

Table 1 Potential clinical preventive services in BC. Summary of the applicable cohort, service frequency and coverage
Full size table

In 2013 the Expert Advisory Committee requested modelling for an additional 9 CPS, followed by 4 in 2015. Each subsequent year the Committee chose 2-4 CPS to (re)model, based on updated CTFPHC or USPSTF results. In 2018, the Committee requested a revision of the CPS modelled to date to incorporate more recent data. In this 2018 update, all costs were adjusted to 2017 Canadian dollars. For consistency, all models completed or revised since 2018 have continued to provide the cost / QALY in 2017 Canadian dollars. The Committee only considered inclusion of preventive maneuvers with a ‘strong’ or ‘conditional (weak)’ recommendation’ by the CTFPHC [53] or an ‘A’ or ‘B’ rating by the USPSTF [54].

In order to prevent duplicate evidence reviews, the Committee agreed to refer any recommendations regarding immunizations to the British Columbia Communicable Disease Policy Committee [55] and any recommendations regarding prenatal care, intrapartum care and immediate postpartum and postnatal care (up to 8 weeks) to Perinatal Services BC [56], thus these CPS are not considered in this manuscript.

Table 1 provides a summary of the 28 CPS reviewed in BC to date. Included in the table are the relevant cohort and the frequency with which the service is to be provided. In addition, an estimated rate of coverage for the service in BC and the best in the world (BiW) are provided.

The primary variables in each model include the effectiveness of the intervention, the quality of life (QoL) values associated with the relevant health state(s) and the costs associated with implementing the intervention and/or avoiding the relevant health state(s).

Effectiveness of the intervention

Table 2 provides a summary of the effectiveness values (and the 95% CI) used in the modelling for each CPS. The effectiveness values are primarily based on evidence reviews completed for the CTFPHC or the USPSTF.

Table 2 Effectiveness values for each CPS used in modelling
Full size table

Quality of life values used in the modelling

The primary source for QoL values were the disability weights developed for the Global Burden of Disease study [95, 96] adjusted to reflect the mean QoL of the age- and sex-specific population under consideration [97, 98]. If disability weights were not available in the Global Burden of Disease study, then meta-analysis or larger studies assessing the QoL for a specific health-related outcome were used.

The CPB was calculated based on benefits minus known harms. For example, we included harms associated with unnecessary follow-up interventions associated with false positive screening results. Harms also include a modest reduction in QoL associated with taking any medication for preventive purposes [99,100,101].

Table 3 provides an overview of the QoL values used in the modelling.

Table 3 Quality of life values used in the modelling
Full size table

Resource unit costs used in the modelling

In calculating CE, we included medical costs and costs to the individual. Medical costs included those associated with screening, counselling, pharmaceutical treatment and any follow-up diagnostic tests and treatments for both true- and false-positive findings. In the model assessing behavioural counselling and interventions for the prevention of alcohol misuse, we also included the costs associated with law enforcement, fire damage and motor vehicle collisions [119]. In the model assessing folic acid supplementation for all women of reproductive age, we also included the special education and developmental service costs associated with caring for a child with a neural tube defect [120]. While the definition of clinical prevention is independent of delivery mechanism or provider type, for costing purposes we chose to use a primary care physician’s office as the delivery mechanism when an established delivery mechanism was not in place in BC. We assumed that 50% of a 10-min visit would be required per CPS unless evidence indicated otherwise.

Costs to the individual include the value of a patient’s time required to travel to an appointment and receive both the CPS and needed follow-up procedures and is based on the average hourly wage rate in BC in 2017 plus 18% benefits [121]. If the ‘50% of a 10-minute visit’ assumption applied, then only 50% of a patient’s time costs were included in the modelling. Overall costs were reduced by potential savings resulting from avoided treatments or less intensive treatments associated with earlier-stage medical care.

When integrating unit cost information into the analyses, priority was given to information available from BC, followed by the rest of Canada, then other high income countries with health care systems similar to Canada (e.g. the UK and Australia) and finally to unit cost information from the US. All unit costs were converted to 2017 Canadian dollars using the Campbell and Cochrane Economics Methods Group and the Evidence for Policy and Practice Information and Coordinating Centre Cost Converter [122, 123]. If US health care unit costs were used, these costs were reduced by 29% to reflect the substantially higher unit costs (or prices) in the US compared to those in Canada for the same output [124,125,126].

Table 4 provides an overview of the unit costs used in the modelling.

Table 4 Unit costs used in the modelling
Full size table

Sensitivity analysis

One-way sensitivity analysis, in which each major variable or assumption in the model was modified, was performed to assess the robustness of the results. We used 95% confidence intervals (CIs) to inform the range for these variables in our sensitivity analyses when the 95% CIs were available. QALYs are not discounted in calculating CPB but both QALYs and costs are discounted by 1.5% in calculating CE, with this rate varied from 0 to 3% in the structural sensitivity analysis [189, 190].

Table 5 presents the range of CE estimates for each CPS together with key variables and the values for the key variables used in the base model and the sensitivity analyses.

Table 5 Potential clinical preventive services in BC. Range of cost-effectiveness estimates based on one-way sensitivity analysis
Full size table

Results

Table 6 provides a summary of the CPB and CE associated with each of the 28 CPS maneuvers. The CPB columns identify the clinically preventable burden (in terms of QALYs) that is being achieved in BC based on current coverage, and the potential CPB if the best coverage rate in the world (BiW) is achieved. Note that coverage rates in BC are unknown for 21 of the 28 (75%) maneuvers. The CE columns identify the cost-effectiveness ratio associated with a service stated in terms of the cost per QALY, using both a 1.5% and a 0% discount rate. The top interventions in terms of CPB are screening for hypertension and screening for cardiovascular disease risk and treatment that would prevent 11,587 and 9370 QALYs lost per 40,000 individuals, respectively. The top interventions in terms of CE are screening women 65 and older for osteoporosis and the application of dental sealants on permanent teeth at the time of tooth eruption, which provide cost savings of $29,412 and $24,690 per QALY (with 1.5% discount), respectively.

Table 6 Potential clinical preventive services in BC. Summary of the clinically preventable burden and cost-effectiveness
Full size table

The results for CPB and CE are displayed together in Fig. 1. The figure is divided into nine segments; from the lowest to highest population health impact and from more expensive to cost-saving. By arranging CPB and CE in this manner, services in the upper right segment have the most favourable combination of CPB and CE while services in the lower left segment have the least favourable combination. While no CPS fall into the high population impact / cost-saving segment, services that fall into the moderate population impact / cost-saving or high population impact / less expensive segments include prevention and cessation of tobacco use in both children/adolescents and adults; initiatives to improve exclusive breastfeeding to 6 months of age; screening for and treatment of hypertension; and screening for cardiovascular disease risk factors and the appropriate initiation of statins. Three additional CPS approach the moderate population impact / cost-saving or high population impact / less expensive segments, namely, alcohol misuse screening and brief counseling, one-time screening for HCV infection in BC adults born between 1945 and 1965, and screening for type 2 diabetes. Screening for osteoporosis, the application of dental sealants and the addition of screening for the human papillomavirus to cytology-based screening for cervical cancers, the CPS with the highest cost savings per QALY, fell in the lowest segment for population health impact.

Fig. 1
figure 1

Establishing Priorities among Effective Clinical Preventive Services in BC. Combining Clinically Preventable Burden and Cost-Effectiveness Summary Results

Full size image

The CBP and CE estimates were fairly stable for most CPS, but varied greatly for some (see Figs. 2 and 3). For example, for the CPS of primary care interventions aimed at smoking cessation among children and adolescents, the estimate of CBP varied from 606 to 8367 QALYs, and the cost-effectiveness estimates ranged from a cost of $23,905 / QALY to a savings of $10,083 / QALY.

Fig. 2
figure 2

Clinically Preventable Burden Based on Providing Clinically Effective Services to a BC Birth Cohort of 40,000 0% Discount Rate

Full size image
Fig. 3
figure 3

Cost Effectiveness Based on Providing Clinically Effective Services to a BC Birth Cohort of 40,000. Best Estimate and Plausible Range of Cost/QALY. 1.5% Discount Rate

Full size image

Other CPS with large variation in the CE were screening women 65 and older for osteoporosis, screening adolescents and adults aged 15 to 65 years for infection with the human immunodeficiency virus, growth monitoring and healthy weight management in children and youth and screening females less than 30 years of age at increased risk for infection with chlamydia and gonorrhea. The most common reason for this variation is the uncertainty associated with the effectiveness of the intervention (see Table 5).

Discussion

We have assessed the clinically preventable burden and cost-effectiveness ratio of 28 clinical preventive services in BC, Canada and found that the services with the highest population impact and best value for money include services that address tobacco use in adolescents and adults, exclusive breastfeeding, and screening for hypertension and other cardiovascular disease risk factors followed by appropriate pharmaceutical treatment. Three additional CPS approach these high-value CPS, namely alcohol misuse screening and brief counseling, one-time screening for hepatitis C virus infection in BC adults born between 1945 and 1965, and screening for type 2 diabetes.

Research by the HealthPartners Institute also established that the two CPS addressing tobacco use in the US were the highest priority preventive services [11]. Despite historically low rates of tobacco use in BC, which are the lowest of any province in Canada [191], tobacco use continues to exert an important influence on the ill-health of the population. Of greater concern is the varying range in the rate of tobacco use in the different geographic regions within BC, from 8.8 to 21.3% in 2011/12 [192]. This suggests the need for equity-focused CPS interventions based on the principle of proportionate universality; preventive services should be universally available, but concentrated on populations with higher rates of the condition or behaviour being addressed [193].

Our analysis also indicates the high value of interventions to support exclusive breastfeeding to 6 months. There are substantial health benefits for both the infant and mother associated with exclusive breastfeeding [58, 120].

Research by the HealthPartners Institute assigned a high value to addressing obesity-related behaviours. Our results for these CPS are more modest, likely due to assumptions about potential coverage rates. Based on the best available information on utilization rates from high-income countries, we assumed that only 7.2% of children [194, 195] and 33% of adults [47] with obesity would complete the multiple sessions over a 1 year period required to achieve an effective intervention [ 11, 49]. These coverage rates compare to the assumption of 90% included in the HealthPartners Institute analysis [196].

The limitations associated with this analysis are common to all modeling studies [197]. Models use data from a variety of sources and the results are only as good as the underlying data. By nature, models also simplify the causal chain so the assumptions made in doing so can have an important impact on results.

Another limitation is the ability to find BiW intervention rates for each CPS. Despite significant effort searching the academic and grey literature, together with expert input, it is not possible to determine whether or not the estimated BiW rates used in the models truly are the BiW. Furthermore, newer CPS such as lung cancer screening may currently have low screening rates that will improve over time. In this scenario, despite a BiW published screening rate of 6% [26], we assumed that the rate for lung cancer screening would eventually approximate rates associated with other cancer screening programs in BC (60%).

The definition of a CPS is independent of delivery mechanism(s) or provider type(s). Determining the most suitable delivery mechanism or provider type for each service is determined in subsequent phases of the policy cycle where decisions are made on whether and, if so, how to implement the CPS. In order to estimate the costs of providing the service and for consistency and comparability between the various CPS, we chose to use a general physician’s office as the delivery mechanism and provider type if an established delivery mechanism is not currently in place. Further work has started in determining if the effectiveness of the intervention changes based on who provides the intervention. For example, evidence indicates that brief behavioural counselling interventions to reduce unhealthy alcohol use are equally effective if provided by nurses, physicians or counsellors / mental health clinicians [198].

The results generated through this process provide a transparent and evidence informed approach to making decisions for the delivery of CPS. It is a key step in determining which CPS should be priorities for BC and is essential for creating a business plan for implementation. These results, however, should not be used in isolation. Actual changes to service provision should be undertaken only when this analysis, a detailed business plan and budget impact analysis are part of the process. These supplementary analyses are important in addressing further questions required in decision-making, such as the feasibility and total costs of enhancing current services or implementing new services and the potential impact on related services.

In BC, this work by the CPPR led to the province adopting a Lifetime Prevention Schedule (LPS), publishing a LPS Practice Guide and providing regular update reports [15]. The work by the CPPR was also a key building block in developing and implementing a preventive services incentive fee for family physicians in the province (the Personal Health Risk Assessment fee [199]), which we believe is unique in Canada. This analysis has also been instrumental in the decision to launch a lung cancer screening program in BC [200]. Finally, the development of business cases to enhance screening for tobacco smoking and alcohol misuse followed by a behavioural counselling intervention are currently in process.

Conclusion

While the results noted above enable us to say with some confidence what is worth doing, the second and third questions asked in our original report remain important: What is the best way to deliver these services and by whom, and what supporting systems need to be put in place to ensure high and equitable coverage of cost-effective services with a moderate to high population health impact? While this discussion has started in BC and key decisions are being made, more remains to be done, both in BC and across Canada. After all, if a CPS is worth doing, it is worth doing well.

Availability of data and materials

A write-up of the detailed modelling approach including all assumptions and results for each individual model are available online at the British Columbia – Lifetime Prevention Schedule website (https://www2.gov.bc.ca/gov/content/health/about-bc-s-health-care-system/health-priorities/lifetime-prevention). In addition to the detailed results for each model included in the “LPS Update Report”, this website also includes a “Reference and Key Assumptions” document that details the methodology behind the Lifetime Prevention Schedule as well as key assumptions used throughout the process. The Excel-based detailed models are available from the lead author upon reasonable request and with permission of the British Columbia Ministry of Health.

Abbreviations

BC:

British Columbia

CPS:

Clinical preventive services

CPB:

Clinically preventable burden

CE:

Cost-effectiveness

CTFPHC:

Canadian Task Force on Preventive Health Care

USPSTF:

United States Preventive Services Task Force

QALYs:

Quality adjusted life years

CPPR:

Clinical Prevention Policy Review

QoL:

Quality of life

CIs:

Confidence intervals

BiW:

Best coverage rate in the world

References

  1. Gorber S, Singh H, Pottie K, et al. Process for guideline development by the reconstituted Canadian Task Force on Preventive Health Care. Can Med Assoc J. 2012;184(14):1575–81.

    Article  Google Scholar 

  2. Lenzer J. Is the United States preventive services task force still a voice of caution? BMJ. 2017;356:j743.

    Article  PubMed  Google Scholar 

  3. McGlynn E, Asch S, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348(26):2635–45.

    Article  PubMed  Google Scholar 

  4. Shenson D, Adams M, Bolen J, et al. Routine checkups don’t ensure that seniors get preventive services. J Fam Pract. 2011;60(1):E1–10.

    PubMed  Google Scholar 

  5. Smith H, Herbert C. Preventive practice among primary care physicians in British Columbia: relation to recommendations of the Canadian Task Force on the Periodic Health Examination. Can Med Assoc J. 1993;149(12):1795–800.

    CAS  Google Scholar 

  6. Ogden L, Richards C, Shenson D. Clinical preventive services for older adults: the interface between personal health care and public health services. Am J Public Health. 2012;102(3):419–25.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Pollack K, Krause K, Yarnall K, et al. Estimated time spent on preventive services by primary care physicians. BMC Health Serv Res. 2008;8(245). https://doi.org/10.1186/1472-6963-8-245.

  8. Yarnall K, Pollack K, Ostbye T, et al. Primary care: is there enough time for prevention? Am J Public Health. 2003;93(4):635–41.

    Article  PubMed  PubMed Central  Google Scholar 

  9. BC Clinical Prevention Policy Review Committee. A lifetime of Prevention. 2009. Available at https://www2.gov.bc.ca/assets/gov/health/about-bc-s-health-care-system/health-priorites/lifetime-prevention-schedule/cppr-lifetime-prevention-report-2009.pdf. Accessed Mar 2021.

    Google Scholar 

  10. Farley T, Dalal M, Mostashari F, et al. Deaths preventable in the U.S. by improvements in the use of clinical preventive services. Am J Prev Med. 2010;38(6):600–9.

    Article  PubMed  Google Scholar 

  11. Maciosek M, LaFrance A, Dehmer S, et al. Updated priorities among effective clinical preventive services. Ann Fam Med. 2017;15(1):14–22.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Maciosek M, Coffield A, McGinnis M, et al. Methods for priority setting among clinical preventive services. Am J Prev Med. 2001;21(1):10–9.

    Article  CAS  PubMed  Google Scholar 

  13. Coffield A, Maciosek M, McGinnis J, et al. Priorities among recommended clinical preventive services. Am J Prev Med. 2001;21(1):1–9.

    Article  CAS  PubMed  Google Scholar 

  14. Maciosek M, Coffield A, Edwards N, et al. Priorities among effective clinical preventive services: results of a systematic review and analysis. Am J Prev Med. 2006;31(1):52–61.

    Article  PubMed  Google Scholar 

  15. Technical reports and additional information about the Lifetime Prevention Schedule are available online at https://www2.gov.bc.ca/gov/content/health/about-bc-s-health-care-system/health-priorities/lifetime-prevention. Accessed Mar 2021.

  16. Lewandowski RE, O’Connor B, Bertagnolli A, et al. Screening for and diagnosis of depression among adolescents in a large health maintenance organization. Psychiatr Serv. 2016;67(6):636–41.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Lefèvre Å, Lundqvist P, Drevenhorn E, et al. Parents’ experiences of parental groups in Swedish child health-care: do they get what they want? J Child Health Care. 2016;20(1):46–54.

    Article  PubMed  Google Scholar 

  18. Hillman JB, Corathers SD, Wilson SE. Pediatricians and screening for obesity with body mass index: does level of training matter? Public Health Rep. 2009;124(4):561–7.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Arlene Cristall, Provincial Lead. The centre for healthy weights – Shapedown BC. 2020. Personal communication.

  20. Jamal A, Dube S, Babb S, et al. Tobacco use screening and cessation assistance during physician office visits among persons aged 11–21 years—National Ambulatory Medical Care Survey, United States, 2004–2010. Morb Mortal Wkly Rep. 2014;63(2):71–9.

    Google Scholar 

  21. Buckingham S, John J. Recruitment and participation in preschool and school-based fluoride varnish pilots–the south central experience. Br Dent J. 2013;215(E8):1–4.

    Google Scholar 

  22. Veiga N, Pereira C, Ferreira P, et al. Prevalence of dental caries and fissure sealants in a Portuguese sample of adolescents. PLoS One. 2015;10(3):1–12.

    Article  CAS  Google Scholar 

  23. National Cancer Institute. Screening and risk factors table: had a mammogram in the past 2 years. 2017. Available at https://statecancerprofiles.cancer.gov/risk/index.php. Accessed July 2017.

    Google Scholar 

  24. National Cancer Institute. Screening and risk factors table: Pap test in past 3 years, no hysterectomy. 2017. Available at https://statecancerprofiles.cancer.gov/risk/index.php. Accessed July 2017.

    Google Scholar 

  25. National Cancer Institute. Screening and risk factors table. 2017. Available at https://statecancerprofiles.cancer.gov/risk/index.php. Accessed Aug 2017.

    Google Scholar 

  26. Huo J, Shen C, Volk R, et al. Use of CT and chest radiography for lung cancer screening before and after publication of screening guidelines: intended and unintended uptake. J Am Med Assoc Intern Med. 2017;177(3):439–41.

    Google Scholar 

  27. Godwin M, Williamson T, Khan S, et al. Prevalence and management of hypertension in primary care practices with electronic medical records: a report from the Canadian Primary Care Sentinel Surveillance Network. Can Med Assoc J Open. 2015;3(1):E76–82.

    Google Scholar 

  28. England PH. Public health outcomes framework. 2017. Available at http://www.phoutcomes.info/search/health%20check#pat/6/ati/102/par/E12000004. Accessed Aug 2017.

    Google Scholar 

  29. Chang K, Lee J, Vamos E, et al. Impact of the National Health Service Health Check on cardiovascular disease risk: a difference-in-differences matching analysis. Can Med Assoc J. 2016;188(10):E228–38.

    Article  Google Scholar 

  30. Helin-Salmivaara A, Lavikainen P, Korhonen M, et al. Long-term persistence with statin therapy: a nationwide register study in Finland. Clin Ther. 2008;30(1):2228–40.

    Article  PubMed  Google Scholar 

  31. Hellgren M, Petzold M, Björkelund C, et al. Feasibility of the FINDRISC questionnaire to identify individuals with impaired glucose tolerance in Swedish primary care. A cross-sectional population-based study. Diabet Med. 2012;29(12):1501–5.

    Article  CAS  PubMed  Google Scholar 

  32. Van den Donk M, Sandbaek A, Borch-Johnsen K, et al. Screening for type 2 diabetes. Lessons from the ADDITION-Europe study. Diabet Med. 2011;28(11):1416–24.

    Article  PubMed  CAS  Google Scholar 

  33. Rui P, Hing E, Okeyode T. National ambulatory medical care survey: 2014 state and national summary tables. Available at http://www.cdc.gov/nchs/ahcd/ahcd_products.htm. Accessed Aug 2017.

  34. Delatte R, Cao H, Meltzer-Brody S, et al. Universal screening for postpartum depression: an inquiry into provider attitudes and practice. Am J Obstet Gynecol. 2009;200(5):e63–e4.

    Article  PubMed  Google Scholar 

  35. Amarnath A, Franks P, Robbins J, et al. Underuse and overuse of osteoporosis screening in a regional health system: a retrospective cohort study. J Gen Intern Med. 2015;12(30):1733–40.

    Article  Google Scholar 

  36. Jacomelli J, Summers L, Stevenson A, et al. Impact of the first 5 years of a national abdominal aortic aneurysm screening programme. Br J Surg. 2016;103(9):1125–31.

    Article  CAS  PubMed  Google Scholar 

  37. Van Handel M, Branson B. Monitoring HIV testing in the United States: consequences of methodology changes to national surveys. PLoS One. 2015;10(4):1–12.

    CAS  Google Scholar 

  38. England PH. Sexually transmitted infections (STIs): annual data tables. 2017. Available at https://www.gov.uk/government/statistics/sexually-transmitted-infections-stis-annual-data-tables. Accessed Aug 2017.

    Google Scholar 

  39. Health Protection Agency. HIV in the United Kingdom: 2012 report. 2012. Available at http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1317137200016. Accessed Aug 2017.

    Google Scholar 

  40. Centers for Disease Control and Prevention. Sexually transmitted disease surveillance 2015. Atlanta: U.S. Department of Health and Human Services; 2016. Available online at https://www.cdc.gov/std/stats15/STD-Surveillance-2015-print.pdf. Accessed Aug 2017

    Google Scholar 

  41. Cullen B, Hutchison S, Cameron S, et al. Identifying former injecting drug users infected with hepatitis C: an evaluation of a general practice-based case-finding intervention. J Public Health. 2012;34(1):14–23.

    Article  CAS  Google Scholar 

  42. Tyler C, Warner L, Gavin L, et al. Receipt of reproductive health services among sexually experienced persons aged 15–19 years—national survey of family growth, United States, 2006–2010. Morb Mortal Wkly Rep. 2014;63(2):2–5.

    Google Scholar 

  43. Kruger J, Shaw L, Kahende J, et al. Health care providers’ advice to quit smoking, national health interview survey, 2000, 2005, and 2010. Prev Chronic Dis. 2012;9:E130.

    PubMed  PubMed Central  Google Scholar 

  44. Bradley K, Williams E, Achtmeyer C, et al. Implementation of evidence-based alcohol screening in the Veterans Health Administration. Am J Manag Care. 2006;12:597–606.

    PubMed  Google Scholar 

  45. Wangberg SC. Norwegian midwives’ use of screening for and brief interventions on alcohol use in pregnancy. Sex Reprod Healthc. 2015;6(3):186–90.

    Article  PubMed  Google Scholar 

  46. McCarty D, Gu Y, Renfro S, et al. Access to treatment for alcohol use disorders following Oregon’s health care reforms and Medicaid expansion. J Subst Abus Treat. 2018;94:24–8.

    Article  Google Scholar 

  47. Fitzpatrick S, Stevens V. Adult obesity management in primary care, 2008–2013. Prev Med. 2017;99:128–33.

    Article  PubMed  Google Scholar 

  48. Fitzpatrick S, Dickins K, Avery E, et al. Effect of an obesity best practice alert on physician documentation and referral practices. Transl Behav Med. 2017:1–10.

  49. Stevens J, Ballesteros M, Mack K, et al. Gender differences in seeking care for falls in the aged Medicare population. Am J Prev Med. 2012;43(1):59–62.

    Article  PubMed  Google Scholar 

  50. Kantor E, Rehm C, Du M, et al. Trends in dietary supplement use among US adults from 1999-2012. J Am Med Assoc. 2016;316(14):1464–74.

    Article  Google Scholar 

  51. Fiscella K, Winters P, Mendoza M, et al. Do clinicians recommend aspirin to patients for primary prevention of cardiovascular disease? J Gen Intern Med. 2013;30(2):155–60.

    Article  Google Scholar 

  52. Malayala S, Raza A. Compliance with USPSTF recommendations on aspirin for prevention of cardiovascular disease in men. Int J Clin Pract. 2016;70(11):898–906.

    Article  PubMed  Google Scholar 

  53. Canadian Task Force on Preventive Health Care. Procedure manual. 2014. Available at https://canadiantaskforce.ca/wp-content/uploads/2016/12/procedural-manual-en_2014_Archived.pdf. Accessed Mar 2021.

    Google Scholar 

  54. Kurth A, Krist A, Borsky A, et al. U.S. Preventive Services Task Force methods to communicate and disseminate clinical preventive services recommendations. Am J Prev Med. 2018;54(1S1):S81–7.

    Article  PubMed  Google Scholar 

  55. See http://www.bccdc.ca/health-professionals/clinical-resources/communicable-disease-control-manual/immunization. Accessed Mar 2021.

  56. See http://www.perinatalservicesbc.ca/health-professionals/guidelines-standards. Accessed Mar 2021.

  57. Forman-Hoffman V, McClure E, McKeeman J, et al. Screening for major depressive disorder in children and adolescents: a systematic review for the US Preventive Services Task Force. Ann Intern Med. 2016;164(5):342–9.

    Article  PubMed  Google Scholar 

  58. Chung M, Raman G, Trikalinos T, et al. Interventions in primary care to promote breastfeeding: an evidence review for the US Preventive Services Task Force. Ann Intern Med. 2008;149(8):565–82.

    Article  PubMed  Google Scholar 

  59. Canadian Task Force on Preventive Health Care. Recommendations for growth monitoring, and prevention and management of overweight and obesity in children and youth in primary care. Can Med Assoc J. 2015;187(6):411–21.

    Article  Google Scholar 

  60. US Preventive Services Task Force. Screening for obesity in children and adolescents: US Preventive Services Task Force recommendation statement. JAMA. 2017;317(23):2417–26.

    Article  Google Scholar 

  61. Canadian Task Force on Preventive Health Care. Recommendations on behavioural interventions for the prevention and treatment of smoking among school-aged children and youth. Can Med Assoc J. 2017;189(8):e310–6.

    Article  Google Scholar 

  62. Marinho V, Worthington H, Walsh T, et al. Fluoride varnishes for preventing dental caries in children and adolescents. Cochrane Database Syst Rev. 2013. Available from https://doi.org/10.1002/14651858.CD002279.pub2.

  63. Ahovuo-Saloranta A, Forss H, Walsh T, et al. Sealants for preventing dental decay in the permanent teeth. Cochrane Database Syst Rev. 2013. Available from https://doi.org/10.1002/14651858.CD001830.pub4.

  64. Fitzpatrick-Lewis D, Hodgson N, Ciliska D, et al. Breast cancer screening. 2011. Available at http://canadiantaskforce.ca/wp-content/uploads/2012/09/Systematic-review.pdf?0136ff.

    Google Scholar 

  65. Peirson L, Fitzpatrick-Lewis D, Ciliska D, et al. Screening for cervical cancer: a systematic review and meta-analysis. Syst Rev. 2013;2(35). Available from https://link.springer.com/article/10.1186/2046-4053-2-35.

  66. Ronco G, Dillner J, Elfström K, et al. Efficacy of HPV-based screening for prevention of invasive cervical cancer: follow-up of four European randomised controlled trials. Lancet. 2014;383(9916):524–32.

    Article  PubMed  Google Scholar 

  67. Canadian Task Force on Preventive Health Care. Recommendations on screening for colorectal cancer in primary care. Can Med Assoc J. 2016;188(5):340–8.

    Article  Google Scholar 

  68. National Lung Screening Trial Research Team. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365(5):395–409.

    Article  Google Scholar 

  69. Law M, Morris J, Wald N. Use of blood pressure lowering drugs in the prevention of cardiovascular disease: Meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies. Br Med J. 2009;338. https://doi.org/10.1136/bmj.b1665.

  70. Chou R, Dana T, Blazina I, et al. Statins for prevention of cardiovascular disease in adults: evidence report and systematic review for the US Preventive Services Task Force. J Am Med Assoc. 2016;316(19):2008–24.

    Article  Google Scholar 

  71. Kahn R, Alperin P, Eddy D, et al. Age at initiation and frequency of screening to detect type 2 diabetes: a cost-effectiveness analysis. Lancet. 2010;375(9723):1365–74.

    Article  PubMed  Google Scholar 

  72. Colman I, Zeng Y, Ataullahjan A, et al. The association between antidepressant use and depression eight years later: a national cohort study. J Psychiatr Res. 2011;45(8):1012–8.

    Article  PubMed  Google Scholar 

  73. O’Connor E, Rossom RC, Henninger M, et al. Primary care screening for and treatment of depression in pregnant and postpartum women: evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2016;315(4):388–406.

    Article  PubMed  CAS  Google Scholar 

  74. Curry S, Krist A, Owens D, et al. Screening for osteoporosis to prevent fractures: US Preventive Services Task Force recommendation statement. J Am Med Assoc. 2018;319(24):2521–31.

    Article  Google Scholar 

  75. Patrick A, Brookhart M, Losina E, et al. The complex relation between bisphosphonate adherence and fracture reduction. J Clin Endocrinol Metab. 2010;95(7):3251–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  76. Girguis-Blake J, Beil T, Sun X et al. Primary care screening for abdominal aortic aneurysm: a systematic evidence review for the US Preventive Services Task Force. Evidence synthesis no. 109. 2014: Available at https://www.ncbi.nlm.nih.gov/books/NBK184793/.

    Google Scholar 

  77. Cohen M, Chen Y, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011;365(6):493–505.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  78. Anglemyer A, Rutherford G, Horvath T, et al. Antiretroviral therapy for prevention of HIV transmission in HIV-discordant couples. Cochrane Database Syst Rev. 2013. Available from https://doi.org/10.1002/14651858.CD009153.pub3.

  79. Hu D, Hook E, Goldie S. Screening for Chlamydia trachomatis in women 15 to 29 years of age: a cost-effectiveness analysis. Ann Intern Med. 2004;141(7):501–13.

    Article  PubMed  Google Scholar 

  80. Jacobson I, Lawitz E, Gane E, et al. Efficacy of 8 weeks of sofosbuvir, velpatasvir, and voxilaprevir in patients with chronic HCV infection: 2 phase 3 randomized trials. Gastroenterology. 2017;153(1):113–22.

    Article  CAS  PubMed  Google Scholar 

  81. Feld J, Jacobson I, Hézode C, et al. Sofosbuvir and velpatasvir for HCV genotype 1, 2, 4, 5, and 6 infection. N Engl J Med. 2015;373(27):2599–607.

    Article  CAS  PubMed  Google Scholar 

  82. Foster G, Afdhal N, Roberts S, et al. Sofosbuvir and velpatasvir for HCV genotype 2 and 3 infection. N Engl J Med. 2015;373(27):2608–17.

    Article  CAS  PubMed  Google Scholar 

  83. Zeuzem S, Ghalib R, Reddy K, et al. Grazoprevir–elbasvir combination therapy for treatment-naive cirrhotic and noncirrhotic patients with chronic hepatitis C virus genotype 1, 4, or 6 infection: a randomized trial. Ann Intern Med. 2015;163(1):1–13.

    Article  PubMed  Google Scholar 

  84. Asselah T, Kowdley K, Zadeikis N, et al. Efficacy of glecaprevir/pibrentasvir for 8 or 12 weeks in patients with hepatitis C virus genotype 2, 4, 5, or 6 infection without cirrhosis. Clin Gastroenterol Hepatol. 2018;16(3):417–26.

    Article  CAS  PubMed  Google Scholar 

  85. Zeuzem S, Foster G, Wang S, et al. Glecaprevir–pibrentasvir for 8 or 12 weeks in HCV genotype 1 or 3 infection. N Engl J Med. 2018;378(4):354–69.

    Article  CAS  PubMed  Google Scholar 

  86. O’Connor E, Lin J, Burda B, et al. Behavioral sexual risk-reduction counselling in primary care to prevent sexually transmitted infections: an updated systematic evidence review for the US Preventive Services Task Force. Ann Intern Med. 2014;161(12):874.

    Article  PubMed  Google Scholar 

  87. Smith A, Chapman S. Quitting smoking unassisted: the 50-year research neglect of a major public health phenomenon. J Am Med Assoc. 2014;311(2):137–8.

    Article  CAS  Google Scholar 

  88. Fiore M, Jaen C, Baker T, et al. Clinical practice guideline. Treating tobacco use and dependence: 2008 update: U.S. Department of Health and Human Services; 2008. Available at http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/clinicians/treating_tobacco_use08.pdf

    Google Scholar 

  89. Curry SJ, Krist AH, Owens DK, et al. Screening and behavioral counseling interventions to reduce unhealthy alcohol use in adolescents and adults: US Preventive Services Task Force recommendation statement. J Am Med Assoc. 2018;320(18):1899–909.

    Article  Google Scholar 

  90. Peirson L, Douketis J, Ciliska D, et al. Treatment for overweight and obesity in adult populations: a systematic review and meta-analysis. Can Med Assoc Open Access J. 2014;2(4):e306–e17.

    Google Scholar 

  91. Michael Y, Whitlock E, Lin J, et al. Primary care-relevant interventions to prevent falling in older adults: a systematic evidence review for the U.S. Preventive Services Task Force. Ann Intern Med. 2010;153(12):815–25.

    Article  PubMed  Google Scholar 

  92. Guirguis-Blake J, Evans C, Senger C, et al. Aspirin for the primary prevention of cardiovascular events: a systematic evidence review for the U.S. Preventive Services Task Force. Ann Intern Med. 2016;164(12):804–13.

    Article  PubMed  Google Scholar 

  93. Chubak J, Whitlock E, Williams S, et al. Aspirin for the prevention of cancer incidence and mortality: systematic evidence reviews for the U.S. Preventive Services Task Force. Ann Intern Med. 2016;164(12):814–25.

    Article  PubMed  Google Scholar 

  94. De-Regil L, Peña-Rosas J, Fernández-Gaxiola A, et al. Effects and safety of periconceptional oral folate supplementation for preventing birth defects. Cochrane Database Syst Rev. 2015. Available from https://doi.org/10.1002/14651858.CD007950.pub3.

  95. Salomon J, Haagsma J, Davis A, et al. Disability weights for the global burden of diseases 2013 study. Lancet Glob Health. 2015;3:e712–23.

    Article  PubMed  Google Scholar 

  96. Institute for Health Metrics and Evaluation. GBD 2016 sequelae, health states, health state lay descriptions, and disability weights. Available online at http://ghdx.healthdata.org/record/global-burden-disease-study-2016-gbd-2016-disability-weights. Accessed Mar 2021.

  97. Sullivan P, Ghushchyan V. Preference-based EQ-5D index scores for chronic conditions in the United States. Med Decis Mak. 2006;26(4):410–20.

    Article  Google Scholar 

  98. Sullivan PW, Slejko JF, Sculpher MJ, et al. Catalogue of EQ-5D scores for the United Kingdom. Med Decis Mak. 2011;31(6):800–4.

    Article  Google Scholar 

  99. Thompson A, Guthrie B, Payne K. Do pills have no ills? Capturing the impact of direct treatment disutility. PharmacoEconomics. 2016;34(4):333–6.

    Article  PubMed  Google Scholar 

  100. Hutchins R, Pignone M, Sheridan S, et al. Quantifying the utility of taking pills for preventing adverse health outcomes: a cross-sectional survey. Br Med J Open. 2015;5(e006505):1–9.

    Google Scholar 

  101. Hutchins R, Viera AJ, Sheridan SL, et al. Quantifying the utility of taking pills for cardiovascular prevention. Circ Cardiovasc Qual Outcomes. 2015;8(2):155–63.

    Article  PubMed  Google Scholar 

  102. Fitzmaurice C, Allen C, Barber R, et al. Global, regional, and national cancer incidence, mortality, years of life lost, years lived with disability, and disability-adjusted life-years for 32 cancer groups, 1990 to 2015: a systematic analysis for the global burden of disease study. J Am Med Assoc Oncol. 2017;3(4):524–48.

    Google Scholar 

  103. Dormal V, Bremhorst V, Lannoy S, et al. Binge drinking is associated with reduced quality of life in young students: a pan-European study. Drug Alcohol Depend. 2018;193:48–54.

    Article  PubMed  Google Scholar 

  104. Schousboe J, Kerlikowske K, Loh A, et al. Personalizing mammography by breast density and other risk factors for breast cancer: analysis of health benefits and cost-effectiveness. Ann Intern Med. 2011;155(1):10–20.

    Article  PubMed  PubMed Central  Google Scholar 

  105. Insinga R, Glass A, Myers E, et al. Abnormal outcomes following cervical cancer screening: event duration and health utility loss. Med Decis Mak. 2007;27(4):414–22.

    Article  Google Scholar 

  106. Krueger H, Lindsay P, Cote R, et al. Cost avoidance associated with optimal stroke care in Canada. Stroke. 2012;43(8):2198–206.

    Article  PubMed  Google Scholar 

  107. Chapman K, Ernst P, Grenville A, et al. Control of asthma in Canada: failure to achieve guideline targets. Can Respir J. 2001;8(Suppl A):35A–40A.

    Article  PubMed  Google Scholar 

  108. Whiteford H, Degenhardt L, Rehm J, et al. Global burden of disease attributable to mental and substance use disorders: findings from the global burden of disease study 2010. Lancet. 2013;382(9904):1575–86.

    Article  PubMed  Google Scholar 

  109. Stade B, Stevens B, Ungar W, et al. Health-related quality of life of Canadian children and youth prenatally exposed to alcohol. Health Qual Life Outcomes. 2006;4:81.

    Article  PubMed  PubMed Central  Google Scholar 

  110. Campbell H, Stokes E, Bargo D, et al. Costs and quality of life associated with acute upper gastrointestinal bleeding in the UK: cohort analysis of patients in a cluster randomised trial. Br Med J Open. 2015;5(4):e007230.

    CAS  Google Scholar 

  111. Hsu PC, Federico CA, Krajden M, et al. Health utilities and psychometric quality of life in patients with early-and late-stage hepatitis C virus infection. J Gastroenterol Hepatol. 2012;27(1):149–57.

    Article  PubMed  Google Scholar 

  112. Ratcliffe J, Longworth L, Young T, et al. Assessing health-related quality of life pre- and post-liver transplantation: a prospective multicenter study. Liver Transpl. 2002;8(3):263–70.

    Article  PubMed  Google Scholar 

  113. Ul-Haq Z, Mackay D, Fenwick E, et al. Meta-analysis of the association between body mass index and health-related quality of life among children and adolescents, assessed using the pediatric quality of life inventory index. J Pediatr. 2013;162(2):280–6.

    Article  PubMed  Google Scholar 

  114. Lamb T, Frew E, Ives N, et al. Mapping the paediatric quality of life inventory (PedQL™) generic core scales onto the child health utility index-9 dimension (CHU-9D) score for economic evaluation in children. PharmacoEconomics. 2018;36:451–65.

    Article  Google Scholar 

  115. Maheswaran H, Petrou S, Rees K, et al. Estimating EQ-5D utility values for major health behavioural risk factors in England. J Epidemiol Community Health. 2013;67(1):172–80.

    Article  PubMed  Google Scholar 

  116. Bertram M, Norman R, Kemp L, et al. Review of the long-term disability associated with hip fractures. Inj Prev. 2011;17:365–70.

    Article  PubMed  Google Scholar 

  117. Kanis J, Oden A, Johnell O, et al. The burden of osteoporotic fractures: a method for setting intervention thresholds. Osteoporos Int. 2001;12(5):417–27.

    Article  CAS  PubMed  Google Scholar 

  118. Grosse S, Flores A, Ouyang L, et al. Impact of spina bifida on parental caregivers: findings from a survey of Arkansas families. J Child Fam Stud. 2009;18(5):574–81.

    Article  Google Scholar 

  119. Rehm J, Gnam W, Popova S, et al. The costs of alcohol, illegal drugs, and tobacco in Canada, 2002. J Stud Alcohol Drugs. 2007;68(6):886–95.

    Article  PubMed  Google Scholar 

  120. Grosse S, Berry R, Tilford J, et al. Retrospective assessment of cost savings from prevention: folic acid fortification and spina bifida in the US. Am J Prev Med. 2016;50(5S1):S74–80.

    Article  PubMed  PubMed Central  Google Scholar 

  121. Statistics Canada. Average hourly wages of employees by selected characteristics and occupation, unadjusted data, by province (monthly) (British Columbia). 2017. Available at http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/labr69k-eng.htm. Accessed Mar 2021.

    Google Scholar 

  122. Shemilt I, Thomas J, Morciano M. A web-based tool for adjusting costs to a specific target currency and price year. Evid Policy. 2010;6(1):51–9.

    Article  Google Scholar 

  123. The Campbell and Cochrane Economics Methods Group and Evidence for Policy and Practice Information and Coordinating Centre. CCEMG - EPPI-centre cost converter. 2021. Available at https://eppi.ioe.ac.uk/costconversion/. Accessed Dec 2021.

    Google Scholar 

  124. Papanicolas I, Woskie L, Jha A. Health care spending in the United States and other high-income countries. JAMA. 2018;319(10):1024–39.

    Article  PubMed  Google Scholar 

  125. Anderson G, Reinhardt U, Hussey P, et al. It’s the prices, stupid: why the United States is so different from other countries. Health Aff. 2003;22(3):89–105.

    Article  Google Scholar 

  126. Reinhardt U. Why does US health care cost so much? (part I). 2008. Available at https://economix.blogs.nytimes.com/2008/11/14/why-does-us-health-care-cost-so-much-part-i/. Accessed July 2017.

    Google Scholar 

  127. Ministry of Health. Medical services commission payment schedule. 2016. Available at http://www2.gov.bc.ca/assets/gov/health/practitioner-pro/medical-services-plan/msc-payment-schedule-december-2016.pdf.

    Google Scholar 

  128. Giardina S, Pane B, Spinella G, et al. An economic evaluation of an abdominal aortic aneurysm screening program in Italy. J Vasc Surg. 2011;54(4):938–46.

    Article  PubMed  Google Scholar 

  129. Silverstein M, Pitts S, Chaikof E, et al. Abdominal aortic aneurysm (AAA): cost-effectiveness of screening, surveillance of intermediate-sized AAA, and management of symptomatic AAA. Bayl Univ Med Cent Proc. 2005;18(4):345–67.

    Article  Google Scholar 

  130. Burgers L, Vahl A, Severens J, et al. Cost-effectiveness of elective endovascular aneurysm repair versus open surgical repair of abdominal aortic aneurysms. Eur J Vasc Endovasc Surg. 2016;52(1):29–40.

    Article  CAS  PubMed  Google Scholar 

  131. Visser J, van Sambeek M, Hunink M, et al. Acute abdominal aortic aneurysms: cost analysis of endovascular repair and open surgery in hemodynamically stable patients with 1-year follow-up. Radiology. 2006;240(3):681–9.

    Article  PubMed  Google Scholar 

  132. Svensjö S, Mani K, Björck M, et al. Screening for abdominal aortic aneurysm in 65-year-old men remains cost-effective with contemporary epidemiology and management. Eur J Vasc Endovasc Surg. 2014;47(4):357–65.

    Article  PubMed  Google Scholar 

  133. H. Krueger & Associates Inc. The economic burden of risk factors in British Columbia: excess weight, tobacco smoking, alcohol use, physical inactivity and low fruit and vegetable consumption. Vancouver: Provincial Health Services Authority, Population and Public Health Program; 2017.

    Google Scholar 

  134. Canadian Substance Use Costs and Harms Scientific Working Group. Canadian substance use costs and harms in the provinces and territories (2007 – 2014). Ottawa: Prepared by the Canadian Institute for Substance Use Research and the Canadian Centre on Substance Use and Addiction; 2018.

    Google Scholar 

  135. Stade B, Ali A, Bennett D, et al. The burden of prenatal exposure to alcohol: revised measurement of cost. Can J Clin Pharmacol. 2009;16(1):e91–e102.

    PubMed  Google Scholar 

  136. Barbeau M, Lalonde H. Burden of atopic dermatitis in Canada. Int J Dermatol. 2006;45(1):31–6.

    Article  PubMed  Google Scholar 

  137. BC Cancer Agency. Screening mammography program: 2016 annual report. 2016. Available at http://www.bccancer.bc.ca/screening/Documents/SMP_Report-AnnualReport2016.pdf.

    Google Scholar 

  138. Gocgun Y, Banjevic D, Taghipour S, et al. Cost-effectiveness of breast cancer screening policies using simulation. Breast. 2015;24(4):440–8.

    Article  CAS  PubMed  Google Scholar 

  139. de Oliveira C, Bremner K, Pataky R, et al. Understanding the costs of cancer care before and after diagnosis for the 21 most common cancers in Ontario: a population-based descriptive study. Can Med Assoc J Open. 2013;1(1):E1–8.

    Google Scholar 

  140. Wai E, Trevisan C, Taylor S, et al. Health system costs of metastatic breast cancer. Breast Cancer Res Treat. 2001;65(3):233–40.

    Article  CAS  PubMed  Google Scholar 

  141. Broekx S, Den Hond E, Torfs R, et al. The costs of breast cancer prior to and following diagnosis. Eur J Health Econ. 2011;12(4):311–7.

    Article  PubMed  Google Scholar 

  142. Kulasingam S, Rajan R, St Pierre Y, et al. Human papillomavirus testing with Pap triage for cervical cancer prevention in Canada: a cost-effectiveness analysis. BMC Med. 2009;7(1):69.

    Article  PubMed  PubMed Central  Google Scholar 

  143. Brisson M, Van de Velde N, De Wals P, et al. The potential cost-effectiveness of prophylactic human papillomavirus vaccines in Canada. Vaccine. 2007;25(29):5399–408.

    Article  PubMed  Google Scholar 

  144. Krahn M, McLauchlin M, Pham B, et al. Liquid-based techniques for cervical cancer screening: systematic review and cost-effectiveness analysis. 2008. Available at https://www.cadth.ca/sites/default/files/pdf/333_LBC-Cervical-Cancer-Screenin_tr_e.pdf. Accessed Aug 2017.

    Google Scholar 

  145. Popadiuk C, Gauvreau C, Bhavsar M, et al. Using the Cancer Risk Management Model to evaluate the health and economic impacts of cytology compared with human papillomavirus DNA testing for primary cervical cancer screening in Canada. Curr Oncol. 2016;23(Supp.1):S56–63.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  146. Sander B, Wong W, Yeung M, et al. The cost-utility of integrated cervical cancer prevention strategies in the Ontario setting–can we do better? Vaccine. 2016;34(16):1936–44.

    Article  PubMed  Google Scholar 

  147. Mariotto A, Robin Y, Shao Y, et al. Projections of the cost of cancer care in the United States: 2010–2020. J Natl Cancer Inst. 2011;103(2):117–28.

    Article  PubMed  PubMed Central  Google Scholar 

  148. Cressman S, Lam S, Tammemagi MC, et al. Resource utilization and costs during the initial years of lung cancer screening with computed tomography in Canada. J Thorac Oncol. 2014;9(10):1449–58.

    Article  PubMed  PubMed Central  Google Scholar 

  149. Ministry of Health. Cardiovascular disease – primary prevention. 2014. Available at http://www2.gov.bc.ca/assets/gov/health/practitioner-pro/bc-guidelines/cvd.pdf.

    Google Scholar 

  150. See BC Reference Drug Program. Available online at http://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/pharmacare/prescribers/reference-drug-program.

  151. Pandya A, Sy S, Cho S, et al. Cost-effectiveness of 10-year risk thresholds for initiation of statin therapy for primary prevention of cardiovascular disease. J Am Med Assoc. 2015;314(2):142–50.

    Article  CAS  Google Scholar 

  152. Dehmer S, Maciosek M, LaFrance A, et al. Health benefits and cost-effectiveness of asymptomatic screening for hypertension and high cholesterol and aspirin counseling for primary prevention. Ann Fam Med. 2017;15(1):23–36.

    Article  PubMed  PubMed Central  Google Scholar 

  153. Gloede T, Halbach S, Thrift A, et al. Long-term costs of stroke using 10-year longitudinal data from the north East Melbourne stroke incidence study. Stroke. 2014;45(11):3389–94.

    Article  PubMed  Google Scholar 

  154. Sadatsafavi M, Lynd L, Marra C, et al. Direct health care costs associated with asthma in British Columbia. Can Respir J. 2010;17(2):74–80.

    Article  PubMed  PubMed Central  Google Scholar 

  155. Bartick M, Reinhold A. The burden of suboptimal breastfeeding in the United States: a pediatric cost analysis. Pediatrics. 2010;125(5):e1048–e56.

    Article  PubMed  Google Scholar 

  156. BC Ministry of Social Development and Poverty Reduction. Dental supplement. 2017. Available online at https://www2.gov.bc.ca/assets/gov/family-and-social-supports/income-assistance/on-assistance/schedule-dentist.pdf.

    Google Scholar 

  157. Canadian Institute for Health Information. Treatment of preventable dental cavities in preschoolers: a focus on day surgery under general anesthesia. 2013. Available at https://secure.cihi.ca/free_products/Dental_Caries_Report_en_web.pdf.

    Google Scholar 

  158. Morgan S, Smolina K, Mooney D, et al. The Canadian Rx Atlas, third edition: UBC Centre for Health Services and Policy Research; 2013. Available at http://www.chspr.ubc.ca/sites/default/files/file_upload/publications/2013/RxAtlas/canadianrxatlas2013.pdf

    Google Scholar 

  159. Pacific Blue Cross. Pharmacy compass. 2018. Available at https://www.pac.bluecross.ca/pharmacycompass.

    Google Scholar 

  160. Wright D, Katon WJ, Ludman E, et al. Association of adolescent depressive symptoms with health care utilization and payer-incurred expenditures. Acad Pediatr. 2016;16(1):82–9.

    Article  PubMed  Google Scholar 

  161. Shepard D, Gurewich D, Lwin AK, et al. Suicide and suicidal attempts in the United States: costs and policy implications. Suicide Life Threat Behav. 2016;46(3):352–62.

    Article  PubMed  Google Scholar 

  162. Clayton D, Barcel A. The cost of suicide mortality in New Brunswick, 1996. Chronic Dis Can. 1999;20(2):89–95.

    CAS  PubMed  Google Scholar 

  163. Kinchin I, Doran CM. The cost of youth suicide in Australia. Int J Environ Res Public Health. 2018;15(4):672–82.

    Article  PubMed Central  Google Scholar 

  164. BC Ministry of Health. MSP fee-for-service payment analysis. 2012/2013 - 2016/2017. Available online at https://www2.gov.bc.ca/assets/gov/health/practitioner-pro/medical-services-plan/ffs_complete.pdf.

  165. Frick K, Gower E, Kempen J, et al. Economic impact of visual impairment and blindness in the United States. Arch Ophthalmol. 2007;125(4):544–50.

    Article  PubMed  Google Scholar 

  166. O’Brien JA, Patrick AR, Caro JJ. Cost of managing complications resulting from type 2 diabetes mellitus in Canada. BMC Health Serv Res. 2003;3(1):7.

    Article  PubMed  PubMed Central  Google Scholar 

  167. Comay D, Marshall J. Resource utilization for acute lower gastrointestinal hemorrhage: the Ontario GI bleed study. Can J Gastroenterol. 2002;16(10):677–82.

    Article  PubMed  Google Scholar 

  168. Ball T, Wright A. Health care costs of formula-feeding in the first year of life. Pediatrics. 1999;103(Suppl. 1):870–6.

    Article  CAS  PubMed  Google Scholar 

  169. El Saadany S, Coyle D, Giulivi A, et al. Economic burden of hepatitis C in Canada and the potential for prevention. Eur J Health Econ. 2005;6:159–65.

    Article  PubMed  Google Scholar 

  170. Myers R, Krajden M, Bilodeau M, et al. Burden of disease and cost of chronic hepatitis C virus infection in Canada. Can J Gastroenterol Hepatol. 2014;28(5):243–50.

    Article  PubMed  PubMed Central  Google Scholar 

  171. Douglass CH, Pedrana A, Lazarus JV, et al. Pathways to ensure universal and affordable access to hepatitis C treatment. BMC Med. 2018;16(1):175.

    Article  PubMed  PubMed Central  Google Scholar 

  172. Hurley R. Slashed cost of hepatitis C drugs spurs drive to eliminate the disease. BMJ. 2018;361:k1679.

    Article  PubMed  Google Scholar 

  173. Williams J, Miners A, Harris R, et al. The cost-effectiveness of one-time birth cohort screening for hepatitis C as part of the national health service health check programme in England. Value Health. 2019;22(11):1248–56.

    Article  PubMed  Google Scholar 

  174. Taylor M, Grieg P, Detsky A, et al. Factors associated with the high cost of liver transplantation in adults. Can J Surg. 2002;45(6):425–34.

    PubMed  PubMed Central  Google Scholar 

  175. Kingston-Riechers J. The economic cost of HIV/AIDS in Canada: Canadian AIDS Society; 2011. Available online at http://www.cdnaids.ca/files.nsf/pages/economiccostofhiv-aidsincanada/$file/Economic%20Cost%20of%20HIV-AIDS%20in%20Canada.pdf

    Google Scholar 

  176. Economic costs associated with mental retardation, cerebral palsy, hearing loss, and vision impairment – United States, 2003. MMWR Wkly. 2003;53(03):57–9.

  177. See http://www.londondrugs.com/search/?q=Folic+acid&lang=default.

  178. Jaquier M, Klein A, Boltshauser E. Spontaneous pregnancy outcome after prenatal diagnosis of anencephaly. BJOG. 2006;113(8):951–3.

    Article  CAS  PubMed  Google Scholar 

  179. Canadian Institute for Health Information. Patient cost estimator. Available online at https://www.cihi.ca/en/spending-and-health-workforce/spending/patient-cost-estimator.

  180. Karen Strange, Project Director. Generation Health, Childhood Obesity Foundation. 2020. Personal communication.

  181. Gustafson A, Khavjou O, Stearns SC, et al. Cost-effectiveness of a behavioral weight loss intervention for low-income women: the weight-wise program. Prev Med. 2009;49(5):390–5.

    Article  PubMed  Google Scholar 

  182. Krukowski R, Tilford J, Harvey-Berino J, et al. Comparing behavioral weight loss modalities: incremental cost-effectiveness of an internet-based versus an in-person condition. Obesity. 2011;19(8):1629–35.

    Article  PubMed  Google Scholar 

  183. Neumann A, Schwarz P, Lindholm L. Estimating the cost-effectiveness of lifestyle intervention programmes to prevent diabetes based on an example from Germany: Markov modelling. Cost Eff Resour Alloc. 2011;9(1):17.

    Article  PubMed  PubMed Central  Google Scholar 

  184. B.C. Ministry of Health, Health Sector Information, Analysis & Reporting Division. MSP fee-for-service payment analysis 2012/2013 - 2016/2017. 2017. Available at https://www2.gov.bc.ca/assets/gov/health/practitioner-pro/medical-services-plan/ffs_complete.pdf.

    Google Scholar 

  185. Hopkins R, Burke N, Von Keyserlingk C, et al. The current economic burden of illness of osteoporosis in Canada. Osteoporos Int. 2016;27(10):3023–32.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  186. Coyte P, Asche C, Elden L. The economic cost of otitis media in Canada. Int J Pediatr Otorhinolaryngol. 1999;49(1):27–36.

    Article  CAS  PubMed  Google Scholar 

  187. Owusu-Edusei K Jr, Chesson HW, Gift TL, et al. The estimated direct medical cost of selected sexually transmitted infections in the United States, 2008. Sex Transm Dis. 2013;40(3):197–201.

    Article  PubMed  Google Scholar 

  188. BC Ministry of Health. Effective pharmacological aids to smoking cessation. 2011. Available at http://www.health.gov.bc.ca/pharmacare/pdf/sc-prod-info.pdf.

    Google Scholar 

  189. Canadian Agency for Drugs and Technologies in Health Methods and Guidelines. Guidelines for the economic evaluation of health technologies. Canada; 2017. Available at https://www.cadth.ca/guidelines-economic-evaluation-health-technologies-canada-4th-edition. Accessed Mar 2021

  190. The National Institute for Health and Care Excellence (NICE). Methods for the development of NICE public health guidance (third edition). Available at https://www.nice.org.uk/process/pmg4/chapter/incorporating-health-economics. Accessed Mar 2021.

  191. Krueger H, Krueger J, Koot J. Variation across Canada in the economic burden attributable to excess weight, tobacco smoking and physical inactivity. Can J Public Health. 2015;106(4):e171–7.

    Article  PubMed  PubMed Central  Google Scholar 

  192. Krueger H, Koot J, Rasali D, et al. Regional variation in the economic burden attributable to excess weight, physical inactivity and tobacco smoking across British Columbia. Health Promot Chronic Dis Prev Can. 2016;36(4):76–86.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  193. Marmot M, Goldblatt P, Allen J, et al. Fair society healthy lives (the Marmot review): Institute of Health Equity; 2010. Available online at http://www.instituteofhealthequity.org/resources-reports/fair-society-healthy-lives-the-marmot-review. Accessed Mar 2021

    Google Scholar 

  194. Fagg J, Chadwick P, Cole T, et al. From trial to population: a study of a family-based community intervention for childhood overweight implemented at scale. Int J Obes. 2014;38(10):1343–9.

    Article  CAS  Google Scholar 

  195. Margaret Yandel, Policy Lead. Office of the Provincial Dietitian. 2020. Personal communication.

  196. Moyer VA. Screening for and management of obesity in adults: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;157(5):373–8.

    PubMed  Google Scholar 

  197. Enderling H, Wolkenhauer O. Are all models wrong? Comput Syst Oncol. 2021;1:e1008.

    PubMed Central  Google Scholar 

  198. Platt L, Melendez-Torres G, O’Donnell A, et al. How effective are brief interventions in reducing alcohol consumption: Do the setting, practitioner group and content matter? Findings from a systematic review and meta-regression analysis. BMJ Open. 2016;6:e011473.

    Article  PubMed  PubMed Central  Google Scholar 

  199. GPSC Services Committee. Prevention incentives. 2018. Available online at http://www.gpscbc.ca/sites/default/files/uploads/GPSC%20Billing%20Guide%20-%20Prevention%20201801.pdf. Accessed Mar 2021.

    Google Scholar 

  200. BC Cancer. B.C. launches lung cancer screening program – the first in Canada. 2020. Available online at http://www.bccancer.bc.ca/about/news-stories/news/2020/b-c-launches-lung-cancer-screening-program-%E2%80%93-the-first-in-canada. Accessed Mar 2021.

    Google Scholar 

Download references

Acknowledgements

We are grateful to the HealthPartners Institute and in particular Dr. Michael Maciosek, who allowed us to use their original US-based models and data and adapt them for our own use in British Columbia.

Funding

Hans Krueger received funding from the BC Ministry of Health in carrying out this work.

Author information

Authors and Affiliations

  1. H. Krueger & Associates Inc., Delta, Canada

    Hans Krueger

  2. School of Population and Public Health, University of British Columbia, Vancouver, Canada

    Hans Krueger, Jane A. Buxton, Bonnie Henry & John J. Spinelli

  3. BC Ministry of Health, Victoria, Canada

    Sylvia Robinson & Bonnie Henry

  4. School of Public Health and Social Policy, University of Victoria, Victoria, Canada

    Trevor Hancock

  5. Department of Family Medicine and Public Health Sciences, Queen’s University, Kingston, Canada

    Richard Birtwhistle

  6. Canadian Task Force on Preventive Health Care, Ottawa, Canada

    Richard Birtwhistle

  7. BC Center for Disease Control, Vancouver, Canada

    Jane A. Buxton

  8. Child Health BC, Provincial Health Services Authority, Vancouver, Canada

    Jennifer Scarr

Authors
  1. Hans Krueger
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Sylvia Robinson
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Trevor Hancock
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Richard Birtwhistle
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Jane A. Buxton
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Bonnie Henry
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Jennifer Scarr
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. John J. Spinelli
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

SR and TH conceived the project, were involved in the design of the work, manuscript revisions and approved the submitted version. HK was involved in the design of the work, completed all data acquisition and analysis, and drafted the work. All other authors were involved in the interpretation of the data and modelling results, manuscript revisions and approved the submitted version.

Corresponding author

Correspondence to Hans Krueger.

Ethics declarations

Ethics approval and consent to participate

This research is based on modeling the effects and costs of 28 CPS using a theoretical birth cohort of 40,000 individuals born in British Columbia. As such, no actual identifiable individuals were participants in the study.

Consent for publication

Not applicable.

Competing interests

None.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Krueger, H., Robinson, S., Hancock, T. et al. Priorities among effective clinical preventive services in British Columbia, Canada. BMC Health Serv Res 22, 564 (2022). https://doi.org/10.1186/s12913-022-07871-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12913-022-07871-0

BMC Health Services Research

ISSN: 1472-6963

Contact us