Sue Ieraci: The balance of prevention and cure

Of all the truisms, “prevention is better than cure” is the one that is heard the most in the current health debate.

It is tempting to take the ideological view that community care, population health and primary care are more worthy, cost-effective and somehow “better”.

In contrast, hospital-based, doctor-driven acute care is somehow “too expensive” and something to be avoided. This polarisation can only increase while a cost-shifting culture persists.

So what happens when preventive strategies are applied in acute care settings?

Emergency departments are often suggested as the sites for recruiting the “captive audience” that can be found there – especially young males suffering trauma.

A team from the University of Michigan recently trialled a brief intervention for reducing violence and alcohol misuse among adolescents who presented to the emergency department of a level 1 trauma centre.(1)

Those enrolled were randomised to receive either a pamphlet listing community resources (control group) or a 35-minute intervention delivered by either an interactive animated computer program or motivational interviewing by a therapist. The interventions involved normative resetting, alcohol refusal and conflict resolution skills practice.

Both groups were contacted at 3 and 6 months and asked about violence and alcohol use.

Although the authors report this as a positive intervention, the accompanying editorial by public health physicians (2) points out problems with the study.

Positive results were noted for only a few outcomes, these outcomes were self-reported by the adolescents themselves and results achieved at 3 months were not sustained at 6.

According to the editorial: “The most proven and effective method to reduce youth drinking, and likely alcohol-related violence, is to implement population-based strategies such as raising alcohol excise taxes and enforcing minimum legal drinking age laws.”

Here lies an important part of the debate that is often missed. Long-term quality of life depends on a range of living conditions including family structure, income, education and employment.

These factors operate outside the health system as they are part of a civil society. So, prevention goes along with cure. Other approaches are needed. One is not nobler than the other.

If we ever get to a system where all parts of health care delivery are funded by a common source, perhaps we can truly assess the cost-effectiveness of different measures and different settings.

The question should not be “is prevention better than cure?” but rather “what balance of preventive and curative measures can our society provide that give the greatest benefit for cost?”

Dr Sue Ieraci is a specialist Emergency Physician with 25 years’ experience in the public hospital system. Her particular interests include policy development and health system design, and she has held roles in medical regulation and management. In addition to her emergency department work, Sue runs the health system consultancy SI-napse.

1. JAMA 2010; 304:527-535.

2. JAMA 2010; 304:575-577.

Posted 23 August, 2010