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Priorities among effective clinical preventive services in British Columbia, Canada

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

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

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

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

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

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

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

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

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

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

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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.

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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.

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Correspondence to Hans Krueger.

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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.

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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

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