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To the Editor: Dr Nelson and colleagues1 found that the rates of safety belt use, mammography, and adult vaccinations increased in most states in the 1990s, while the rates for other important health risk factors and clinical preventive services varied or worsened. The authors note that state mandates for insurance coverage of mammograms were one likely contributor to the increase in the rates of mammography. Although state mandates may play a role in increasing the delivery of other clinical preventive services, preliminary data demonstrate that state mandates currently apply to an inconsistent array of preventive services.2 State mandates are most common for mammography, but few states mandate coverage of counseling and behavioral interventions to address unhealthy behaviors such as tobacco use, alcohol use, and other risk factors. More states (n=27) mandate coverage of prostate cancer screening than colorectal cancer screening (n=17), despite the fact that much stronger evidence exists for the benefits of screening for colorectal cancer.
The US Preventive Services Task Force reviews the evidence about which preventive services are effective in the general population and makes recommendations about the use of such services.3 This information could help guide the formulation of state mandates to ensure that the services covered by mandates are supported by scientific evidence of effectiveness. The process for developing state mandates, however, does not consider such evidence in a consistent way. This can lead to mandates for services that may be outdated (eg, baseline mammograms in young women) or those for which proof of effectiveness is lacking (eg, prostate cancer screening). Rathore et al4 found significant variation in the details of state mandates for cancer screenings, including the guidelines followed and service specifics.
As the study of Nelson et al shows, health risk factors and delivery of some clinical preventive services have not improved or are getting worse. As health care costs escalate, we believe that it is important for state mandates to reflect evidence-based recommendations about preventive care and the prevention priorities within a state. State trends and comparisons, as presented by Nelson et al, can be a useful tool in identifying such priorities. Further research is needed to determine whether mandates are an effective tool in improving delivery of appropriate preventive care.
This letter was shown to Dr Nelson, who declined to reply.—ED.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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