Integrating Clinical Care and Community Health: Title and subTitle BreakDelivering Health

Health care and public health professionals in the United States can look at their achievements over the last century with pride. Increasing the life span of Americans by almost one-third of a year each year over an entire century is an enormous and unprecedented accomplishment. The virtual elimination of many childhood illnesses, control of cardiovascular disease and stroke, effective treatment of pneumonia, and reductions in infant mortality exemplify the remarkable progress made. Along with changes in the social and physical determinants of health, these improvements are often attributed either to application of better medical knowledge or to public health actions, but have really required both.

Public health professionals generally think about how to improve health at a population level, whereas clinicians generally address the needs of individuals. These streams converge in systems of clinical care and are also embodied in population health principles of measurement, system change, and accountability. For example, safe and effective immunizations require timely delivery. School immunization requirements, outreach programs, up-to-date schedules, reminder systems, financial incentives, and education made it possible for clinicians to ensure those vaccines were delivered. Employers and others took delivery of influenza vaccination to work sites and community locations. Registries were created, immunization rates were tracked, and feedback was provided.

As strategies for controlling tobacco, hypertension, and hyperlipidemia emerged, clinicians collaborated with public health officials on education programs; screening; pharmaceutical management; and tobacco prevention, cessation programs, and policies to reduce use. New initiatives in urban planning and mass transit that encourage walking and biking complement school and employer-based programs to enhance physical activity.

Although much progress has been made, tobacco, physical inactivity, poor diet, alcohol, and substance use remain the highest ranked causes of death today. Microbial agents, toxins, motor vehicle crashes, firearm injuries, and harmful sexual behaviors also continue to take an unnecessary toll.¹ These problems contribute to the burdens of cardiovascular disease, cancer, diabetes, and lung disease, all illnesses that can be solved only by the synergistic efforts of clinical medicine and public health.

Economic resources flowing into health care technologies continue to increase much more rapidly than inflation, while resources to support health improvements at the population level remain scarce.² Because ever increasing sums are spent on services of uncertain value,³ there is growing recognition of the importance of evidence-based medicine and evidence-based public health to provide the scientific basis for identifying and delivering the services that really improve health outcomes and provide good value. For clinical preventive services, the US Preventive Services Task Force, which publishes the Guide to Clinical Preventive Services, has led the way in rigorously examining screening, counseling, and chemoprevention strategies.⁴ More recently, the Community Preventive Services Task Force has used analogous, rigorous methods to identify the population-targeted services that improve health.⁵ These interventions are wide-ranging—patient and clinician education, financial and other incentives, reminders, risk assessments, improved systems of care, and policies in both public and private sectors, including socioeconomic and environmental policies. They are codified in the Guide to Community Preventive Services.⁵

These 2 guides are actually more closely related than may be apparent. The audiences for the recommendations in both guides include clinicians and public health practitioners; those responsible for ensuring the delivery of high-quality health care services to populations, such as health plans and employers; and those who shape the environments and behaviors of populations, such as schools and planners. The methods of the 2 task forces are also analogous; both use the tools of epidemiology to assess evidence and make recommendations based on the strength of evidence as well as the magnitude of effect. Thus, there should be high confidence that implementation of strong recommendations made by either task force will have substantial health benefits.

Cancer Screening. There are important synergies achievable by implementing the recommendations of both guides. For example, cancer screenings, such as for colorectal, breast, and cervical cancer, are highly effective services when delivered to the appropriate populations.⁴ However, less than 70% of women aged 50 to 79 years in commercial plans and less than 50% of women in Medicaid plans reporting to the National Committee for Quality Assurance are up-to-date on mammography.⁶ Screening rates are poorer for colorectal cancer. Only 56% of adults in commercial plans and 50% of adults in Medicare who should be screened actually are screened.⁶ Nonetheless, these numbers represent substantial improvement. Much of the gain can be attributed to the application of quality improvement and public health principles and community guide recommendations, including clinician assessment and feedback, clinician and patient reminder systems, one-on-one education, use of small media (videos, letters, brochures, and newsletters), and reduction in structural and financial barriers.⁵ These effective interventions need to be implemented at multiple levels, including health systems and clinical practices, employers and other payers, and community-based groups, as well as government public health agencies.

Improving Physical Activity. Physical inactivity presents a more complex problem. At the population level, there are effective strategies for reducing physical inactivity, including point of decision prompts (eg, signs by elevators encouraging use of stairs), street-level and community-level urban design and land use practices, access to recreational areas with community education, individually adapted physical activity programs, social supports, physical education and activity in schools, and community-wide campaigns.⁵ Although clinician counseling to improve physical activity has not been convincingly shown to be effective,⁴ clinicians can nonetheless play other important roles to change behaviors. As knowledgeable community leaders, clinicians can work with public officials, community organizations, and businesses to develop and implement effective programs; they can refer patients to effective programs for social support or individually adapted programs that are difficult to provide in a busy clinician's office; and they can be effective spokespersons about the need to change the physical environment to be more conducive to physical activity.⁷

Securing Value. Although all services recommended by the Guide to Clinical Preventive Services and the Guide to Community Preventive Services are effective, they differ enormously in effect size and cost-effectiveness. The recommended clinical preventive services have been assessed on these dimensions and there are orders of magnitude of difference between the services providing the most value (eg, childhood immunizations, smoking cessation counseling, and aspirin prophylaxis) compared with those at the bottom of the list (eg, adult tetanus-diphtheria boosters, cholesterol screening in high-risk men aged <35 years or women aged <45 years, and diabetes screening).⁸ Policy interventions are often more powerful than individual-level services. Not only do they reach the broad population, but they also do not require labor-intensive, one-on-one delivery mechanisms. Examples include clean indoor air laws that have dramatically reduced smoking rates and rates of smoking-related illness⁹ ; locating schools away from freeways can dramatically reduce the frequency and severity of asthma attacks¹⁰ ; laws lowering blood alcohol levels for intoxication to 0.08% have decreased motor vehicle fatalities a median of 7%¹¹ ; and use of sobriety check points has reduced fatal crashes by 20% to 26%.¹¹ Understanding the relative value of alternative strategies should inform decisions about where to spend time and money.

The US health system too often fails to deliver effective clinical and population-based services as well as continues to deliver ineffective ones. Both lead to inefficiencies and wasted resources. Redirecting those wasted resources to effective programs and policies will enhance value. However, not all effective services are created equal. Economic evaluations and priority setting efforts can help identify the opportunities that provide the greatest value.

Great progress has been made, yet the knowledge base on the effectiveness of community preventive services is remarkably sparse. Although there are recommendations for more than 200 community-based preventive services, this is a fraction of the high-priority interventions that need to be assessed. Still more work is needed to assess the synergistic effects of clinical and community-based interventions. Targeted primary research is needed to fill the information gaps found by the systematic reviews. A research enterprise that devotes so much energy to the development of innovative medical technologies also needs a commensurate translational research agenda to ensure the effective delivery of those interventions, to continuously monitor their implementation, and to assess their real effect in terms of health outcomes and economic value, and their distributional effects by geography, ethnicity, age, and sex.

Disparities in health remain unacceptable but are not solvable solely within the health care system. To eliminate them, the underlying social and economic determinants must be addressed. Information on the effectiveness of interventions is frequently inadequate to provide information relevant for different ethnic and racial groups, children, elderly persons, and other important segments of the population. The paucity of information about how to close those gaps needs to be remedied—with both more primary studies including these groups as well as more concerted effort to assess them in systematic reviews—and effective strategies implemented. Refocusing research energies on these salient issues should allow capitalizing on the effective and valuable available interventions.

To continue improving the US health system, the synergies that come from closer collaboration of the population health and clinical care systems are essential. These solid roadmaps for achieving better health must be followed.