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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.
2. JAMA 2010; 304:575-577.
Posted 23 August, 2010
Not better, but different – and there is no logical reason why health promotion or preventative health should come from the same budget as acute medical care.
One of the most effective preventative measures for road trauma is better roads – dual carriageways, eliminating “black spots” etc. Roads budgets, not health. Clean water, safe housing…not the health budget but very important to one’s health.
Preventive care will never decrease the lifetime mortality rate which is going to remain at 100% for the forseeable future. If modifying my diet and blood pressure means I infarct at 75, not 55, then I still need CCU – and possibly 20 years of dietician input and antihypertensives. Overall cost increase. That will be MORE than offset by the additional 10 years I have in the workforce. We can and should afford both preventative and acute care, but the former should be paid for by the projected extra earnings, not projected and probably imaginary savings from the latter.
Emergency Physicians are not the people to be offering preventative care – we aren’t trained for it, keeping up with what we are trained for takes most of the time we can give to learning, and we are getting a little fed up with the response to almost every need (Drug and Alcohol management, prolonged psychiatric assessment, contact tracing, forensic examinations, extended POC testing, Hospital in the Home, After hours speech pathology) of “train Emergency Doctors to do it.” By all means set up a booth in the ED waiting room offering Preventive health interventions if it is thought patients will respond.