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(2009-10-29 01:56:12)










分类: 医疗卫生


阿尔弗雷德·A·博弗(Alfred A. Bove):医学博士、美国心脏病学会基金会会长

 Longevity, Prevention, and Health Care Reform

By Alfred A. Bove  胡德良 

 I want to discuss prevention in this month's President's Page, but I am hesitant to use the word "prevention" because there are some who say that prevention is too expensive and that we cannot afford a health system that is responsible for caring for people into their 90s. Prevention has taken on a significant role as a goal in health care reform discussions. Primary care providers point to prevention as one of their main advantages, and prevention is put forward as a major means of reducing health care costs. We have seen the evolution of entire industries aimed at keeping people healthy into old age—or, even better, at preventing aging in the first place.


 Prevention as it relates to longevity would enable people to participate in the workforce for more years, contributing their training and experience, and in general, one would expect high efficiency from these healthy middle-aged and older workers. Prevention and longevity in a different context relate to how most people envision their retirement as a time of travel and leisure. They do not usually consider it as a time of frequent hospital admissions and physician visits to maintain stability with a chronic disease.


 However, in all of its permutations, prevention is clearly a process that involves the individual patient more than the physician. Indeed, a physician's contribution is focused primarily on medical therapies, while patients must be focused on maintaining a normal body weight, following healthy behaviors such as not smoking and foregoing excess alcohol or other drugs, exercising adequately, following a healthy diet, adhering to medication orders, and visiting their health care providers periodically for screening of early disease.


 Cardiologists should encourage their patients to maintain healthy behavior and provide them with guidance on reducing cardiovascular disease (CVD) risk. Interestingly, I find that patients understand the concept of longevity better than the concept of prevention. Perhaps it is because longevity describes health maintenance goals with distant time horizons, while prevention sounds like medical therapy for the present only. Patients grasp that lowering blood pressure to normal levels and taking medication on a long-term basis will get them to their mid-80s in good health. This makes more sense conceptually than taking medicine to avoid a stroke.


 The Cardiologist's Role


 Trying to manage prevention in otherwise healthy people would overwhelm both cardiologists and primary care physicians. In their study of CVD history, Ford et al. (1)showed that 43% of the reduction in cardiovascular deaths was due to lifestyle changes, and 47% could be attributed to improved cardiovascular care. Yet, public campaigns still emphasize more immediate goals, and many people who start on prevention programs soon lose interest because they see no immediate effects. Often they need to take a medication for hyperlipidemia or hypertension, and because they see no apparent short-term advantage, they stop taking the medication.


 However, cardiologists have a limited prevention role when it comes to seemingly healthy people. Despite the high number of asymptomatic people who have hypertension, many—particularly those who are 35 to 50 years old—will not make contact with a health care provider until they develop a cardiovascular event. By that time, it is too late for prevention. Cardiologists are most likely to be visited by patients seeking care for cardiac disorders. It is rare for an asymptomatic, young person to visit a cardiologist.


 Prevention Costs and Health Care Reform


 Studies that assess the cost for a quality life-year usually demonstrate excess cost for prevention if a statin or an antihypertensive medication is needed. With lifestyle changes alone (weight control, exercise, not smoking, and a balanced diet), the cost of prevention is very low. Health care economists indicate that a cost of $50,000 for a quality life-year would be an acceptable balance between outcome and cost. In most cases, statin use for prevention of atherosclerosis in individuals in the 40- to 50-year age range exceeds this number, and as a population benefit, cost would be prohibitive.


 However, cost cannot be the only factor considered, particularly if we believe there is a societal imperative to provide good health into later life. Currently we have a moral imperative to provide good care for our patients, to diagnose and treat disease, to reduce morbidity and mortality, and to ensure a productive life for them into their 80s.


 Many say that cost should not dominate in these decisions, and I agree. If providing good care means medication for controlling lipids and blood pressure or prescribing an antiplatelet agent to prevent stent thrombosis, the patient's well being should predominate over cost.


 On the other hand, in the cases of therapies that have been proven to not add longevity, cost does become an important consideration. It is this concern over the cost of inappropriate therapies and tests that is a key element of the current health care reform debate.


 Secondary Prevention and Continuity of Care


 In the prevention of subsequent illness in patients who have CVD, which is considered secondary prevention, much of the effort involves continuity of care. Treatment of hypertension can be done with home monitoring and reporting. Heart failure is best stabilized over time with frequent communications by telephone or other means, and patients with arrhythmias and/or implanted devices need frequent surveillance to remain in a stable state of health. Patients with chronic coronary disease need medication, lifestyle changes, exercise programs, and frequent surveillance to maintain stable health.


 However, at present, physicians are not reimbursed for providing either primary or secondary prevention programs. That said, prevention and continuity of care programs are performed using telephone, e-mail, or other Internet-based communication systems. When successful, these programs reduce morbidity, hospital days, emergency visits, and even regular office visits for which we are currently paid.


 In this time of intense debate about health care reform, it is essential that we move the reimbursement system toward recognition of the value of continuity of care and prevention. Our goal of providing a program that fosters cardiovascular health for individual patients, and for the public at large, can be met with programs focused on these goals, but we cannot provide this service if there is no compensation.


 In the health care debate, the American College of Cardiology has taken the position that there should be reimbursement for continuity of care by cardiologists. This argument also applies to the need to provide more reimbursement to primary care physicians. For patients with chronic CVD, we should take this role and should be compensated appropriately. If the mix of payments covers usual office visits, the needed procedures and tests, and continuity of care for primary and secondary prevention, we might reduce the dependency on tests for practice income and avoid the pressure for price controls that we know is an unsuccessful means of controlling health care costs. The health care reform debate should lead to legislation late in 2009, and the legislation should include meaningful payment reform that is aimed at improving health, instead of paying for sickness.




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