Another review of Prevention vs. Treatment: What’s the Right Balance?

Bhaven Sampat has written a review of our text in Global Public Health 8(2):236-9, 2013. His summary judgment is:

Having expressed some minor complaints, I emphasise that I like the book and recommend it. I have long been interested in teaching a course on cost-effectiveness analysis that goes beyond technique and engages some of the political and ethical issues behind the scenes. This volume would be a good introduction to these themes in the context of prevention and treatment. The first three chapters would also provide a very good short introduction to the prevention versus treatment debates for policymakers and others interested in a general overview of these issues.

The first three chapters include the introduction (Faust and Menzel), economics (Altarum Institute – Miller, Roehrig, Hughes-Cromwick, and Turner), and cost-savings/effectiveness (Russell). We’re pleased he liked these chapters and they tend to be the most quoted of the chapters on policy-related blogs.

Let’s look at his “minor complaints.”

First, he doesn’t think the third section of the text, on how religious perspectives look at the balance, are valuable. “Though these chapters provide a useful introduction to medical ethics issues from different traditions, I do not think they connect well with the other chapters or speak to the balance question.” Given that other reviewers have praised the connectedness of the chapters, I’d like to better understand what he means by that portion of his comment. But more importantly, his “speak to the balance question” comment is puzzling. Each chapter in the third section specifically looks at how each religion represented considers how to balance prevention and treatment. The problem is that, except for Seventh Day Adventism (SDA), they all come out on the side of treatment without actually making the comparison in their religious texts or commentaries, except as gleaned from isolated statements.

This was surprising to Paul and me as well – none of Protestantism, Catholicism, or Judaism explicitly address the balance between treatment and prevention. This is the interesting finding from this section. When pushed, the authors of these chapters, who originally all stated there is no preference stated, eventually intuited that indeed treatment is commanded to take precedence in most instances (except in the “community elders” argument of Judaism). And even when Roy Branson’s chapter on SDA went a little deeper he found it easy to conclude that while prevention was still very important historically and theologically, there could be some concern that the SDA treatment system, which today is one of the largest in the US, is overwhelming in its use of resources, worrying that it could crowd out the prevention orientation.

Perhaps Sampat thought that they don’t address the balance question because indeed within the traditions they don’t explicitly address it, and he confused that with not asking or addressing the question within the chapters?

To the second minor complaint I plead guilty: I approached the book originally with the strong bias that prevention is underfunded and we don’t devote sufficient attention to it in policymaking or in the clinic. The latter is demonstrable with the under-use of prevention resources, even those considered cost-saving and cost-effective. This bias was stated explictly in the introduction, wherein Paul and I illustrate this underfunding and under-attention emphasis in various settings and the US’ clear bias toward treatment and away from prevention. This has been my stance throughout my career and I still believe it correct. And here is how I believe, from a policy perspective, this conclusion is dispositive: everyone talks about how treatment care costs too much – and by “health care” they usually mean “treatment” care. And everyone talks about how we don’t do enough in prevention. Yet we continue to pay for treatment care (almost at any cost) even when we know that additional dollars to prevention could help (but not cure) under-utilization of prevention. I address this in chapter 6 of our text, where I point out that funding alone (e.g. first dollar funding of prevention by the Affordable Care Act) won’t fix the access and other issues associated with successful prevention for individuals and communities.

Having said this, Sampat would be surprised to find how much my own view and public stances on prevention have changed since beginning the book. Now instead of speaking in full defense of prevention I add nuances of concern and reality. I even have one talk, “The Moral Problem of Prevention,” where I explicitly point out these concerns and why prevention might not take the theoretical moral high road which it used to take.

I agree also with Sampat’s concern that we didn’t spend more time on both the politics of prevention (mostly just covered in Diana Petitti’s chapter) and how the values-attitudes mix impacts both policy and individual decision-making. I call for more imagination in effecting the “affect heuristic” in prevention – we need to figure out how we can evoke better future suffering because of a lack of prevention in order to have decision-makers understand better their effects when they don’t fund prevention. Indeed the theme of the American College of Preventive Medicine’s 2015 meeting will be just that – Imagination in Preventive Medicine, from a policy and delivery perspective.

Generally those who practice prevention both in the public health and private clinical spheres have not been very good at marketing health to their stakeholders. Certainly marketing techniques like those used for unhealthy products and services have evolved into fine arts – glossy well-designed corporate annual reports, while many public health programs still use the equivalent of xeroxed, hand-folded brochures. We need to find efficient, effective ways to deliver better messages, motivate people in different directions, and change tastes (literally).

Perhaps Paul Menzel and I will produce volume 2, which would address some of Sampat’s minor complaints. Maybe he’d like to explore the political context more? We would have liked to have addressed some of his complaints in our first volume, but frankly were concerned about going over 400 pages for practical publication purposes.

At the same time, we thank him for his comments and review.

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Nice Review of Prevent vs. Treat by Linda Hill

As an admittedly boastful statement, I am pleased with Linda Hill’s review of Menzel’s and my Prevention vs. Treatment:  What’s the Right Balance? in the June, 2012 edition of the American Journal of Preventive Medicine.  The concluding paragraph reads:

Impressively, the author of each chapter is aware of the material discussed in the other chapters and is able to put his or her own discussion in the larger context. This must have required tight coordination among authors including sharing of drafts, as well as superb editing. This is a thoughtful and very well written text, contributing in a meaningful way to the fıeld.

While I am proud of the statements by Linda, my real reason for posting this review information is to call attention to the AJPM search for a new editor-in-chief (EIC). The AJPM has done remarkably under the current editorial staff, lead by Kevin Patrick, the EIC,  and his managing editor, Charlotte Seidman.  Both have decided to retire from their AJPM responsibilities at the end of 2013 after almost 20 years – a remarkable tenure for any journal editor.  The journal’s Board of Governors (of which I am one) is now searching for their successors.  The call for applications or nominations for the EIC can be found here.  If you know of anyone capable and interested in this position, please don’t hesitate to contact the Journal secretary or treasurer (listed on the website link above), or me.  Thanks.

Does Prevention Save Money?

There is a significant difference between something saving money (net reduction in total expenditure) and being cost-effective (requiring less cost per outcome than something else). Sarah Kliff from the Washington Post takes on this question by discussing Louise Russell’s chapter 3 in Menzel’s and my edited text, Prevention vs. Treatment: What’s the Right Balance? Doug Kamerow also addresses this question in more layman’s terms in his new text, Dissecting American Health Care, Commentaries on Health, Policy, and Politics (RTI Press, p. 29).

The argument Kliff looks most at is related to the table Russell shows (figure 3.1) by Joshua Cohen, et. al. that appeared in the New England Journal of Medicine in 2008. According to Google Scholar this article has been cited 195 times since its publication.

It seems to me there is one problem with Cohen, et. al.’s article: it lumps together apples and oranges in its comparison. To compare all well-defined studies of prevention with all well-defined studies of treatment ends up comparing such disparate items as genetic screening for inborn errors of metabolism and surgery for elderly men with prostate cancer. On a macro basis this may be the best we can do when asking the economic question of prevention vs. treatment. But such comparisons seem besides the point when mixed together. I’d rather see comparisons of like-minded prevention and treatment. For example, how does preventive statin use compare with coronary artery bypass surgery? Or more broadly, how does screening and reduction of risk factors for heart disease compare with treatment of preventable heart disease?

A discerning eye can see that prevention cannot impact all types of heart disease, e.g., already established unexplainable congenital heart defects, or right heart failure due to hereditary chronic lung disease. Many (perhaps most) diseases we find in medical textbooks do not have easily defined causes which can be short-circuited by prevention maneuvers. Just as we cannot prevent a disease in a non-at-risk population (i.e., a population that cannot get the disease in the first place – men don’t get ovarian cancer; women who’ve had total hysterectomies cannot get uterine cancer), we cannot prevent a disease for which we do not know predisposing risk factors or causative agents.

[Let me be clear that this doesn’t mean we can’t prevent disease without knowing its proximate cause. Scurvy was prevented in sailors without knowing about vitamin C per se; it was prevented by an observation of the relationship of the lack of citrus fruits and the profound spread of scurvy among sailors. In this case citrus fruits were a surrogate for the active vitamin C ingredient. There are many other such examples in the history of preventive medicine. See, for example. Burt Gerstman’s Epidemiology Kept Simple, 2003, p 290]

One other problem with the cost-effectiveness analyses typically done: they discount the value of future lives. This almost automatically puts prevention at a disadvantage because by definition the effects of prevention are in the future, while the effects of treatment are usually gained in the short-term. So for every life saved in treatment this year, we would need two or more lives saved in the future through prevention if we discount lives. This has interesting ethical implications, the most obvious of which is: why is a life in the future worth less than a life right now? Menzel explores this issue in detail in chapter 11 of Prevention vs. Treatment and I won’t recount his discussion here other than to say that the economic rationale of discounting monetary value most likely doesn’t hold for the value of life, especially when an ethical analysis is done. Because we make health policy including not just dollars but also values, this may hold a very telling modification of the policy implications of Russell’s analysis.

PSA Screening and Prostate Cancer

Making health policy involves many different aspects of life:  scientific evidence of a highly predictive diagnostic test, reasonable price, competing resource demands, comfort and convenience of a test, seriousness of the disease being detected, impact of the disease on the individual and the population, etc.

Anyone who’s been involved in health policy debates will recognize that, except for predictive value of the test and actual cost of the test, both of which can be determined somewhat objectively, all of the rest of the items listed above are laden with values (and one can argue even arriving at the predictive value involved significant calls on various values in doing the studies).   Evidence-based medicine only provides information, it doesn’t provide a support of values and how they will be applied in society.

Rather than reproduce some of the less-than-obvious arguments about screening for prostate cancer here, those interested can find more information in Paul Menzel’s and my recent posting on the Oxford University Press blog website.

Lying vs. Reporting Child Abuse

Joe Palazzolo is a reporter for the Wall Street Journal. On November 8, 2011 he reported on the legal issues related to the Penn State scandal. In his article, “Child-Abuse Reporting Law is Challenge to Prosecutors” he states:

Some observers wonder why lying to a grand jury about knowledge of child-abuse allegations carries a stiffer punishment than failing to report them in the first place.

This is, to some extent, a parallel issue to why we prioritize treatment over prevention. If there is any doubt that we do, read chapter 1 of Paul Menzel’s and my recently published text, Prevention vs. Treatment: What’s the Right Balance? (Oxford University Press, 2011).

To answer Palazzolo’s quandary, in essence we consider breaching trust in testimony more harmful to society than preventing harm to children. The first preserves the integrity of our society. The second should preserve the integrity of individuals. Sometimes we prioritize one over the other, sometimes not.

Note that this is an explanation of how society has made legislation, not a justification. Most legislation is made linearly, not comparatively. Nobody sat down and said, “Is child abuse more or less important than lying?” The juxtaposition of the two occurs now because of the peculiar circumstances and conditions of the Penn State case. Is it the right balance? Will the Pennsylvania legislature see this juxtaposition and take action to either reduce penalties for perjury, or increase penalties for failing to report child abuse? Only those in Pennsylvania who vote and could put pressure on their legislatures will determine that question. It would be interesting to know, however, if the same relative penalties exist in most other states. Any lawyers out there who can research the questions?