PREVENTIVE

4, 183-225

MEDICINE

(1975)

SPECIAL REPORT Preventive Health Care Strategies for Health Maintenance Organizations PETER B. PEACOCK American

Health

Foundation.

ANNA Columbia

University

School

New

York,

New

York

10019

C. GELMAN

of Public

Health,

New

York,

New

York

10032

AND THEODORE American This Health have health hood dentistry. provided baseline

paper

reports

Maintenance

Health the

Foundation,

results

Organizations

New

of a study and

other

been selected for review-initial and education, chronic disease prevention, and adolescence, mental health services, Recommendations by an HMO health profile

are

made

with suggestions of each participant.

A. LUTINS

of preventive health

care

New

York

health deliverers

10019 care

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appropriate

health medical

services

in the

periodic screening, health the maternity cycle and drug abuse and alcoholism,

as to how for

York,

care histories

U.S.

offered Nine

by areas

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might formulate

be a

I. INTRODUCTION

The Health Maintenance Organization Act of 1973 (Public Law 93-222) stipulates that each member of a “Health Maintenance Organization” be provided with certain defined “basic health services.” These basic health services include physician’s services, some hospital services, medically necessary emergency health services, short-term out-patient and crisis intervention mental health services, medical treatment and referral services for the abuse of or addiction to alcohol and drugs, diagnostic laboratory and diagnostic and therapeutic radiologic services, home health services, and preventive health services. Except for the requirement that “preventive health services” include voluntary family-planning services, infertility services, preventive dental care for children and children’s eye examinations conducted to determine the need for vision correction, the term “preventive health services” is not defined in the act. By disease prevention we usually mean the taking of those measures which will reduce the incidence of new disease (for any given age group) or limit the progression of any disease state that does occur. Good medicine includes both 183 Copyr&ht @ 1975 by Academic Press. Inc. All rights of reproduction in any form reserved.

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good preventive care and good therapeutic care with no sharp distinction between the two. There are many ways of classifying disease prevention. Using the relationship between cigarette smoking and disease as our example, the three most widely used models are: (a) the transmission model. Prevention is divided into (1) attacking the disease agent (e.g., reducing the tar content of cigarettes); (2) reducing opportunities for transmission (e.g., not making cigarette vending machines available to teenagers); (3) increasing the resistance of the host (e.g., maintaining a high exercise level so as to develop cardiac collateral circulations). (b) the method or systems approach model. Prevention is divided into (1) the managerial or environmental approach (e.g., passing legislation banning the use of cigarettes in public places); (2) the individual approach involving behavior modification by the individual being protected (e.g., learning to give up cigarettes). (c) the stage-of-intervention model, supposedly based on the natural history of disease. Prevention is divided into (1) primary prevention or intervening before any disease process is manifest (e.g., persuading parents to give up smoking so that their children will not follow their bad example); (2) secondary prevention involving the early diagnosis of actual or incipient disease and intervening before serious pathological changes have occurred (e.g., persuading individuals with reduced lung function to give up cigarette smoking before they acquire fully developed emphysema). While the words used may be different and differences of opinion are inevitable on what the operational scope of preventive medicine might be, a feeling of unanimity does run through the outline descriptions of preventive medicine found in most of the standard texts. Preventive medicine is that aspect of a physician’s practice in which he applies to individual patients the knowledge and techniques from medical, social and behavioral science to prevent disease or its progression. The preventive-minded physician is alert for chances to prevent the occurrence and progression of diseases among patients and families, an alertness which must usually be acquired . . it becomes second nature for the physician to be on the lookout for congenital defects in the newborn, for rehabilitation needs among stroke victims, for opportunities to improve the immunization status of his patients, for cautioning against poisons left around the home within reach of toddlers, for malnutrition among his older patients . . . for emotional danger signals among teen age patients and for the early signs of mental disorder among young and old married couples.

From: Preventive Medicine; Principles of Prevention Progression of Disease. Hilleboe, H. H. and Larimore, Co. Philadelphia, Pa., 1965.

in the Occurrence and G. W. W. B. Saunders

The preoccupations of . . . preventive medicine (are) specific and personal, dealing as they do with such conditions as the immunization of the individual against certain communicable diseases, the state of his nutrition, the early treatment of incipient disease, and the application in each case of the available skills of medicine and surgery and of community organization for the prevention of the sequelae of serious illness . . . preventive medicine is or should be a part of medical practice.”

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From: Preventive Medicine in Modern Practice. Committee on Public Health Relations of the N.Y. Academy of Medicine. Paul B. Hoeber, Inc. Medical Book Department, Harper Brothers, New York, 1942, Third Edition. Prevention in its narrowest sense means averting the development of a pathological state; more broadly it includes also all the measures which halt progression of disease to disability or death . . Under the broader definition, all definitive treatment of disease may be considered preventive. . . . Freedom from chronic illness can be achieved only through . . . effort (1) toward health promotion; (2) toward averting the occurrence of illness and (3) toward early detection of disease through health examinations and . . . screening . . . to assure treatment in early stages that will prevent disability or premature death.

From: Chronic Illness in the United States. Vol I, Prevention of Chronic Illness. Commission on Chronic Illness. June 1949-June 1956. Harvard University Press. Cambridge, Mass., 1957. Published for the Commonwealth Fund. Prevention in a narrow sense means averting the development of a pathological state. In a broader sense it includes all the measures-definitive therapy among them-that limit the progression of disease at any stage of its course. A distinction is commonly made between these two major types of prevention: 1. Primary prevention means averting the occurrence of disease. 2. Secondary prevention means halting or slowing the progression of a disease or its sequelae at any point after its inception.”

From: Preventive Medicine, Editors, Little Brown, Boston, Mass., 1967.

Clark, Duncan W., and MacMahon,

Brian.

“Preventive medicine is the science and art of preventing disease, prolonging life and promoting physical and mental health for individuals and families by private health practitioners, medical and dental, through intercepting disease processes through community and individual action.” The authors proceed to describe five levels of prevention: (1) Health promotion; (2) Specific protection; (3) Early detection and treatment; (4) Disability limitation; and (5) Rehabilitation.

From: Preventive Medicine for the Doctor in his Community. Leavell, H. L. and Clark, E. G. The Blakiston Division, McGraw Hill Book Co., New York, 1965, 3rd Edition, It has been stated (1) that the health system can be converted from a complaint-response to a health-maintenance focus by maintaining surveillance over five parameters of health where the detection and treatment of largely asymptomatic deviations prevent much disability and premature death. The following listing has been adapted and enlarged from these initial five parameters. Individual needs determined by age, sex, occupation, marital status, geographic residence, and so on, may modify this list. I. immunological parameters. A complete immunization history should be obtained and attention given to diseases for which immunizing agents are generally recommended (measles, poliomyelitis, tetanus, diphtheria, rubella, pertussis) or recommended under special conditions (e.g., smallpox, cholera, yellow fever, typhoid, rabies). History of adverse allergic reactions to penicillin, horse serum, etc. should be carefully recorded and possible recurrences avoided. 2. Serological parameters. These provide evidence of subclinical infection with communicable diseases such as syphilis, histoplasmosis, and other mycotic infections, and should be used for Rh sensitivity determinations (pregnant females), etc.

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3. Microbiologic parameters. These provide evidence of subclinical infections with gonorrhea, tuberculosis, malaria, amebiasis, etc. and a variety of helminthic infections such as those produced by pinworms and hookworms. This evidence may be particularly valuable among contacts of cases and others at high risk. Occupation may determine additional examinations to be done such as testing for brucellosis among dairy farmers and slaughter house workers. 4. Chemical parameters. Deviations from expected “normals” of blood components such as glucose, cholesterol, triglycerides, uric acid, hemoglobin, serum globulins, lead, mercury, cadmium, etc., may be suggestive of increased risk or early disease. 5. Anatomical parameters. These include structural defects such as recurrent dislocations, scoliosis, obesity, lumps in the breast, thyroid, lymph glands, prostate, rectum, lesions disclosed by X-ray, visible skin discolorations, rashes, and nevi. Structural defects in the oral cavity such as malocclusion and crowding or wide spacing of teeth also need attention. 6. Physiological parameters. These include elevated blood pressure, EKG abnormalities, elevated intraocular pressure, and diminished respiratory capacity. 7. Sensory parameters. Defects in vision, hearing, smell, taste, and touch require attention. 8. Genetic parameters. The finding of chromosomal aberrations by karyotyping the biochemical testing of amniotic fluid through amniocentesis, PKU testing, sickle cell anemia, and trait determinations are all important. 9. Behavioral parameters. Evidence of agitation, depression, excessive use of alcohol and other drugs, excessive use of cigarettes and overeating are examples of behavioral deviations that are relevant to disease prevention. REFERENCE 1.

Breslow, L., and Collen, M. F., Eds. Consumer-defined goals-For the health care systems of the 1980’s. Technology and Health Care Systems in the 1980’s, Department of Health Education and Welfare, Publ. (HSM) 73-3016, January, 1972 pp. 113-123.

II. WHY SHOULD HEALTH MAINTENANCE ORGANIZATIONS EMPHASIZE DISEASE PREVENTION?

For a preventive health program to be justifiable in the context of a health maintenance organization: 1. A substantial number of enrollees with the health maintenance organization should benefit in terms of reduced mortality, morbidity, days in hospital, lost work time, pain and discomfort, long-term complications, and expense related either directly or indirectly to unnecessary illness and disability. 2. The expenditures in money and manpower required from the deliverer of health care to stimulate, develop and operate these preventive health care services should be comparable to or less than that would be needed to provide the same amount of patient benefit through improved therapeutic care or other means. There is good evidence that these two requirements can both be met provided:

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(a) selectivity is used in determining what preventive health services should be provided in terms of both the services themselves and the subpopulations being served; (b) the preventive health services are not regarded as separate from the rest of the health care system but are fully integrated with this system; (c) the preventive health care services are conducted with at least the same degree of enthusiasm and devotion to duty as characterizes the therapeutic services; (d) allowance is made for the aspirations and beliefs of the populations being served and the input and support of these populations are sought and obtained; (e) it is always remembered that (in contrast to therapeutic care) the persons who actively seek preventive health care may well be those who need it least and a positive effort must be made to go to the population being served rather than wait for them to come to the deliverer of care. In the succeeding sections of this report we will look in more detail at a number of areas that need consideration in any preventive health service (a) initial and periodic screening; (b) health hazards appraisal; (c) health education; (d) chronic disease prevention; (e) the maternity cycle and the neonate; (f) childhood and adolescence; (g) mental health services; (h) drug abuse and alcoholism; (i) preventive dentistry. Following this we will look briefly at what is already being done by selected health maintenance organizations and other health care deliverers across the country. From this some suggestions will be developed concerning the potential of health maintenance organizations to fulfill their potential and provide true health maintenance. III. A. INITIAL

AND PERIODIC

HEALTH

EXAMINATIONS

(SCREENING)

The immediate purpose of most initial and periodic health examination programs is the identification and recording of disease processes (or disease precursors) in a defined population. Most of the readily available literature on this subject reflects the experiences of involved protagonists in the United States, the United Kingdom and, to a lesser extent, the British Commonwealth and Sweden. In the United States they usually describe the organization and activities of large industrial medical departments and privately sponsored examination groups. Screening literature includes descriptions of one-time public-health-sponsored community health fair types of activity; activities of individual disease-detection and disease-prevention-oriented foundations (e.g., heart, cancer, diabetes); office and hospital experience with multiple biochemical examinations; and technological descriptions of equipment, automation, and computerization. The populations under scrutiny are primarily older employed adults who provide a relatively high yield of previously undetected chronic disease and risk factors predisposing to such disease. The results of the examination programs are biased by the self-selection of participants or employers and the scientific interests of the investigators. In most cases, the examiner is not the regular physician of the examinee or a member of a medical group to which the patient belongs. Unless the personal physician of the patient is interested in informing

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the examination center about the disposition of the case there is virtually no way of knowing whether the early detection of disease or its precursors (risk factors) prevented the occurrence or progression of disease, disability, or death. To the best of our knowledge there are relatively few papers which describe the long-term status of persons who were found to have had a remedial abnormality or were at high risk of developing serious chronic disease and who were adequately treated and followed. Most publications are concerned with a description of what was done and what was found and not with the effect on the future health of the examinee. Follow-up appears to be the most difficult part of the procedure and is the most neglected. However, without follow-up, answers about the real value of presymptomatic health examinations per se cannot be given. The most valuable material available on this subject has been produced by the Kaiser-Permanente Health Plan at Oakland, Calif. which has been following a sample of their enrollees since 1964. This sample consisted of 5000 subjects and 5000 controls who were between the ages of 35 and 54 yr when the study was initiated and was selected from a group of 43,000 members of the Kaiser Permanente Health Plan at Oakland. Other attempts have been made to retrospectively evaluate the effects of such health examinations on the future status of examinees but Kaiser-Permanente is the largest prospective program which was originally designed with evaluation as an objective and has been in service long enough to adequately evaluate the effects of early detection and intervention on outcome in a relatively stable insured population. According to their findings, presymptomatic examinations with adequate follow-up and reexaminations show promise of reducing morbidity (including hospital utilization), disability, and mortality in the persons in the experimental group (5-7,21). It will be of interest to compare their findings with those of a group in Britain which is also conducting a j-year longitudinal survey of health usage and sickness absence in screened and control groups (23). The advantages of a multifaceted health evaluation (screening) for participants in an HMO contract where the HMO is both the examiner and provider of medical care are: (i) it will serve to identify the symptomatic patient and make it possible to initiate prompt treatment; (ii) it will serve to identify subclinical or hitherto undetected existing disease and make it possible to initiate prompt treatment: (iii) it will serve to detect those risk factors or precursors of chronic disease which while themselves not constituting clinical disease are associated with a greater probability of later developing manifest clinical disease and make it possible to begin a course of action to minimize their effect. The findings with respect to the two latter objectives are hopefully such that: (a) the tests are reliable, the findings reproducible, and the yield contains a minimum of false positives and negatives; (b) enough is known about the disease, its symptoms, causes, prevention, and treatment for intervention to check its progression or damaging outcome; (c) the risk factors can be eliminated, reduced, or controlled without doing more harm than good in the process; (d) their elimination, reduction, or control will be followed by a reduced probability of developing manifest clinical disease; (e) methods of attacking the risk

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factors are acceptable within the structure (mores, beliefs, economics, and interrelationships) of the individuals and community involved; (f) there are adequate trained personnel, medical facilities, and funds to provide the necessary services on a continuing basis. The question is always being raised about the benefits derived from “screening” patients for conditions other than those which bring them to seek medical care and the periodic repetition of the same examinations. While much has been published on the subject of case-finding and risk factor detection through the “annual check-up”, surprisingly little of this has been devoted to an evaluation of specific tests and on whether their inclusion in the “battery” can be justified. Needless to say, these tests did not arise out of thin air and have presumably been included because they have always been considered to be part of the diagnostic armamentarium of competent, thorough practitioners of therapeutic medicine. Current practice, both here and abroad, dictates that a certain number of examinations which are generally acceptable to both patients and physicians be administered for presymptomatic, symptomatic, and differential diagnoses. There are other specialized examinations which are selectively requested if the situation requires them. New tests are occasionally added but not too many of them survive or become widely acceptable. Some are dropped because they have not proved as sensitive, specific, or reliable as an older test; others because they have outlived their usefulness. Such procedures as the mammogram and triglyceride determination have been added within relatively recent years; some like the Papanicolou cytology examination have already withstood the test of 20 years. Only occasionally will one of the “old packages” be discarded and then under protest. The waning popularity of the chest X-ray for minimal tuberculosis in favor of the tuberculin test followed by a chest X-ray when needed, was due to the antiradiation propaganda, not the fact that the tuberculin test was cheaper, easier to administer and read, and adequate for screening purposes. Usually decisions to exclude tests are difficult to make due to years of habitual use. One of the greatest problems facing the decision makers is determining what constitutes the boundary between “normal” and “abnormal” when applied to healthy populations. Most of the examinations included in health-appraisal examinations have proved their worth in the presence of symptoms when performed in conjunction with other relevant examinations. Whether isolated “abnormal” findings in a presumably healthy person are indicative of disease or risk factor can only be established after several decades of careful collection and analysis of organized data. Similarly, only long-term, well-designed and executed longitudinal studies of adequately large samples drawn from a cross section of the American public can determine whether the detection and correction of these “abnormalities” lead to reduced future morbidity, disability, and mortality among the intervention groups as compared with those in the general population whose medical care has not included such examinations and follow-up. Excluding those items in the medical history (e.g.. occupational and travel history, record of cigarette smoking), and physical examination (e.g., cervical bruits) which carry a diagnostic and prognostic significance to the well-trained

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physician, there are a large number of special procedures and laboratory tests which have been used by screening centers in recent years. The California Medical Association lists some 37 of these procedures performed by at least five out of seven of the major multiphasic testing programs operational in the United States in 1971. Several major disease problems in adults can be identified early through initial screening or periodic health examinations. Opinions differ widely among health care practitioners as to the benefits to the patient and community in terms of morbidity, disability, mortality, costs, and hospitalization when those conditions are detected before and after symptoms appear. Certain aspects of the evidence for and against screening for specific chronic diseases will be presented later in the section on chronic disease. It may be of interest to look briefly but critically at the evidence for and against some of the tests that are used in routine adult screening. Anthropometry

It has been known for many years from life insurance data that persons with a weight in excess of 30% above the standard for their age, sex, and height have a considerably reduced life expectancy. The excess deaths occur from diabetes, pneumonia, congestive heart failure, cancer of the breast and corpus uteri among other causes. Unfortunately, there is very little evidence that weight control programs started in adult life (except for highly motivated individuals) have acceptable success rates. When intensive weight reduction programs have been initiated in childhood or adolescence, better results have been claimed, but long-term follow-up is generally lacking. Audiometry

and Visual Acuity

It is known that the correction of audiometric and visual defects found through screening does not increase life expectancy as such but such corrective action does improve the quality of life and may either increase the earning capacity of some persons, prevent others from losing their employment, and prevent avoidable accidents at home, in the community, and at place of employment. Cardiovascular

The strongest evidence for the benefits to be gained from a screening program in adults lies in the cardiovascular area. Blood pressure (3,22), serum cholesterol (4,17,19), triglycerides, electrocardiographic abnormalities (16), the smoking habit, raised red ( 10) and white cell counts (12) and an elevated uric acid (11,15) have all been related to an increased risk of coronary artery disease. Of these factors, the blood pressure, cholesterol level and, to a lesser extent, the smoking habit, all lend themselves to possible correction with a real hope of reducing the incidence of first attacks of coronary artery disease. The secondary prevention of rheumatic fever is also of established value in extending life expectancy.

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Blood Chemistry

The evidence that detecting abnormal bilirubin levels or blood urea nitrogens can extend life expectancy is still controversial. The same comment applies to the determination of blood proteins. The early detection of abnormalities of calcium and phosphorus may benefit a few persons with parathyroid disease, but even this is doubtful (24). Glucose

Tolerance

In a recent review (1974) on screening for diabetes appearing in the Newsletter of the American College of Preventive Medicine, Professor Ann Browder concluded with “Screening is useful only insofar as treatment follows which is more effective before symptoms than after their onset. This sequence is not yet proved for diabetes mellitus.” Unfortunately, when prophylactic chemotherapy has been used, this negative opinion is the only one that can legitimately be drawn from presently available data. Life style changes (diet, exercise, smoking, etc.) may well be beneficial, but a well-controlled trial has not been done. Hematology

While the routine search for microcytic anemia and the administration of iron to persons with hemoglobin levels of under 10 gm% is accepted as routine in most medical circles, the evidence is shaky that this procedure has any beneficial effect in most apparent cases of microcytic anemia in younger women. In one study by Elwood (9) it was found impossible to correlate symptoms (irritability, palpitations, dizziness, fatigue, headaches) with the level of hemoglobin, either before or after treatment, when appropriate blind techniques were used. On the other hand, among elderly people it has been shown (I) that over 50% of middleaged men with iron-deficiency anemia had demonstrable intestinal pathology when complete barium GI series were done. In this same age group it has also been shown that the intake of folic acid drops to about two-thirds of normal and borderline folic acid deficiency is not uncommon. White cell counts are occasionally of value in making possible the early diagnosis of chronic infective conditions which can then be treated. Enzymes

Abnormalities of LDH and alkaline phosphatase are sometimes important in detecting serious underlying disease (e.g., cancer of the prostate) but there is .as yet no convincing evidence that early detection of any of these conditions can dramatically increase the life expectancy of those concerned. The SGOT test has been used for the diagnosis of liver illness, gallbladder disease, kidney disease, and heart disease. It has been most widely used for the early diagnosis of infectious hepatitis (in the preicteric stage) and for detecting cirrhosis in chronic alcoholics. One study (20) found that of 290 cases of infectious hepatitis, only 7% gave normal readings (ranging around 40 Wroblewski units) while 80% gave values above 400 units. In 60 cases of chronic hepatitis, 50 yielded readings above 100, with 20 above 200, while among 65 cases of alcoholic cir-

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rhosis, 25% gave readings at or above 300 units. The disadvantage of this test is that the false negative and the false positive rates are high, and particularly that the false positive cases demand extensive additional investigation. Serology and Gonococcal

Cultures

The value of syphilis serology is unquestioned but it is only among populations at high risk that the cost can be justified of doing this on a routine basis. In one report from Saskatchewan, Canada, it was noted that the yield from serological tests for syphilis was less than one positive per 40,000 tests done! Of more potential value is the new ability to test for gonorrhea, and gonococcal cultures should now be routine in many settings. The yield can be expected to be high and the results of treatment are good. Urinalysis Urinalysis is done (apart from testing for sugar) for proteinuria and bacteriuria. Levels of proteinuria greater than 150 mg over 24 hours are generally regarded as pathological (14) although simple orthostatic proteinuria has a reasonably good prognosis. Such a proteinuria may be glomerular, tubular, or mixed in origin. In one study (25) in which 303 women who were tested for bacteriuria of pregnancy lo-14 years earlier and followed successfully it was found that of those who were originally bacteriuric (whether treated with sulfonamides or with placebo) about 25% were still bacteriuric while only 5% of those who were originally nonbacteriuric had become bacteriuric. Some one-quarter of those who were bacteriuric lo-14 years previously showed moderate pyelographic evidence of chronic pylonephritis. These findings are still not universally accepted (as far as the significance of the bacteriuria is concerned) and there does not seem to be any truly effective treatment available at the present time, but detection of this condition so as to be able to recommend sensible living would seem to be advisable. Tonometry Probably the best recent review on the subject of tonometry (13) suggests that the prevalence of clinical glaucoma (tension greater than 2 1, cupping of the disc, field loss) is between 0.5 and 0.7%. For most normal persons the distribution of pressures is Gaussian around 16, with a standard error of 3 mm Hg, but there is an excess with pressures over 21 which include the truly glaucomatous population. Of 232 ocular hypertensives followed for 43 months, only one developed a field defect. In another study of 138 ocular hypertensives, two developed field changes over 5 years compared with one out of 500 with normal tension. Thus, although there is an overlap, the sensitivity and specificity of the test is such as to make it worth while as a preliminary screen. Whether it is possible to treat these ocular hypertensives so that they do not go on to develop more severe glaucoma is still questionable. In one reported study (18) of 42 such persons who were diagnosed and treated, three developed glaucomatous changes over 5 years. It is believed, however, that advances can be expected in this area.

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Chest X-Ray Given our present knowledge, the costs of routine chest X-rays are difficult to justify except in selected populations. Except where transmission rates .of tuberculosis are still very high (a few isolated Indian tribes) a preliminary skin test makes much more sense if the purpose is to diagnose tuberculosis early. There is no evidence that early diagnosis of cancer of the lung has any favorable influence on life expectancy. For persons who might be exposed to one of the pneumoconioses, the argument in favor of routine chest X-rays is more convincing but even here caution must be exercised. Diagnosis does make it possible to remove the individual concerned from the source of the dust and possibly to correct the situation and prevent others from developing similar conditions. On the other hand, most of these conditions do not lend themselves to treatment and progress (especially with silicosis) may continue even after the subject is removed from exposure to silica dust. Spirometry The enthusiasm for spirometry has waxed and waned. For example, the state of Georgia has at present a very extensive program whereby the Lung Society tests some 20,000 persons a year in an attempt to diagnose emphysema early. Unfortunately, the false positive rate is very high for this test and there is also disappointingly little evidence that the early diagnosis of emphysema benefits the subject. Cancer Detection Despite the tremendous amount of work that has been done in cancer research only a limited number of primary risk factors have been identified. The control of cigarette smoking would by itself by a tremendous step forward in the prevention of cancer. Changed sexual habits will reduce the incidence of cancer of the cervix and reduced exposure to sunlight can beneficially influence the incidence of cancer of the skin. There is some evidence that the early diagnosis of cancer of the breast, cancer of the cervix, cancer of the large bowel, cancer of the oropharynx, and Hodgkin’s disease is associated with an increased life expectancy. Much of this is still contentious but definitive trials are being conducted at the present time and hopefully favorable answers will emerge from these trials. The tone of this analysis to this point, with the exception of the risk factors for heart disease, may appear generally discouraging. We must remember, however, that the HMO has an enrollment covering all age groups. In other age groups appropriate testing can yield tremendous dividends. At prenatal clinics the early diagnosis of syphilis, Rh incompatibility, diabetes, hypertension, disproportion, excess weight gain, drug addiction, and goiter in the expectant mother can all lead to corrective measures which will greatly reduce morbidity and mortality in the infants born of these women. These programs are both acceptable and practicable. The identification and screening programs of populations of children who have not been fully immunized against diphtheria, whooping cough, measles, and polio can all be followed by highly effective corrective measures and in older

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groups, tetanus immunizations are helpful and rubella immunizations will protect unborn children. For selected special groups, smallpox, typhoid, BCG, and mumps immunizations are of proven value. In the area of accident prevention keeping persons with abnormal vision, with epilepsy, and with certain forms of mental disease from the wheel of motor vehicles can yield major dividends. Dental Screening With regard to dental caries, the following quote from a paper (8) by Eisner and Oglesby is self-explanatory. “An example of a screening program in which costs outweigh benefits is dental screening. In this example, the screening cost itself may be so high in relation to treatment that it is cheaper to treat everyone than it is to screen out the children who do not need treatment. This is in part because the prevalence of dental caries among children who have not received regular dental care is so high. If ninety-five per cent of the children in a school have untreated cavities, then referral of all of them for treatment is the equivalent of a screening test with five per cent over-referrals and no under-referrals. The cost of bringing in the over-referrals for treatment that proves unnecessary and does not get done is inconsequential in comparison to what it would cost for professional examination of each child in a screening program.” Within certain populations specific screening tests can be justified. Among blacks, sickle cell screening has a role and among older persons a particular check for osteoporosis can be justified. For adolescent girls in certain socioeconomic groups testing for pregnancy so as to make early diagnosis and early abortion possible may be a legitimate and worthwhile program. Among children with repeated infections testing for agammaglobulinemia is justified. For persons exposed to excess light, albinism should be a ground for exclusion while among miners anhydrosis is equally potentially dangerous and there is some evidence that persons with dark skins should not be exposed to the possibility of being infected with Coccidioides immitis. Among children in slum communities special hematology for lead poisoning may play a role. There is an increasing amount of evidence in favor of glucose-6-phosphate dehydrogenase screening among possibly susceptible populations. REFERENCES 1. 2. 3. 4.

Andrews, J. Aspects of malnutrition in the elderly. Proc. Nub. Sm. 27, 196-201 (1968). Brown, D. F. Blood lipids and lipoproteins in atherogenesis. Amer. J. Med. 46, 69 l-704 (1969). “Build and Blood Pressure Study,” Vol. 1. Society of Actuaries, Chicago, 1959. Chapman, J. M., and Massey, F. J. The interrelationships of serum cholesterol, hypertension, body weight and risk of coronary disease. Results of the first ten years follow-up in the Los Angeles Heart Study. .I. Chronic Dis. 17, 933-949 (1964). 5. Collen, M. F., Dales, L. G., Friedman, G. D., Flagle, C. D., Feldman, R., and Siegelaub, A. B. Multiphasic checkup evaluation study. 4. Preliminary cost benefit analysis for middle-aged men. Prev. Med. 2, 236-246 (1973). 6. Cutler, J. L., Ramcharan, S., Feldman, R., Siegelaub, A. B., Campbell, B., Friedman, G. D., Dales, L. G., and Collen, M. F. Multiphasic checkup evaluation study 1. Methods and population. Prev. Med. 2, 197-206 (1973). 7. Dales, L. G., Friedman, G. D., Ramcharan, S., Siegelaub, A. B., Campbell, B., Feldman, R.,

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22. 23. 24. 25.

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and Cohen, M. F. Multiphasic checkup evaluation study. 3. Outpatient clinic utilization, hospitalization and mortality experience after seven years. Prev. Med. 2, 221-235 (1973). Eisner, V., and Oglesby, A. Health assessment of school children. V. Selecting screening tests. .f. Sch. Health 42, 21-24 (1972). Elwood, P. C. Some epidemiological problems of iron deficiency anemia. Proc. Nutr. Sot. 27, 14-23 (1968). Elwood, P. C., Waters, W. E., Benjamin, I. T., and Sweetnam, P. M. Mortality and anemia in women. Lancet 1, 891-894 (1974). Fessel, W. J., Siegelaub, A. B., Johnson, E. S. Correlates and consequences of asymptomatic hyperuricemia. Arch. Intern. Med. 132, 44-54 (1973). Friedman, G. D., Klataky, A. L., Siegelaub, A. B. The leukocyte count as a predictor of myocardial infarction. N. Engl. J. Med. 290, 1275-1278 (1974). Graham, P. A. Epidemiology of simple glaucoma and ocular hypertension. Brit. 1. Ophthalmol. 56, 223-228 (1972). Jensen, H. Proteinuria. A survey Dan. Med. Bull. 19, 89-98 (1972). Kannel, W. B., Castelli, W. P., and McNamara, P. M. The coronary profile: 12-year follow-up in the Framingham Study. J. Occup. Med. 9, 611-619 (1967). Kannel, W. B., Dawber, T. R., Friedman, G. D., Glennan, W. E., and McNamara, P. M. Risk factors in coronary heart disease. An evaluation of several serum lipids as predictors of coronary heart disease. The Framingham study. Ann. Intern. Med. 61, 888-899 (1964). Keys, A., Taylor, H. L., Blackburn, J., Brozek, J., Anderson, J. T., and Simonson, E. Coronary heart disease among Minnesota business and professional men followed fifteen years. Circulation 28, 381-395 (1963). Norskov, K. Routine tonometry in ophthalmic practice. II. Five year follow-up Acta Ophthalmol. 48, 873-895 (1970). Paul, O., Lepper, M. H., Phelan, W. H. Duperties, G. W. McKean, A., and Park, W. A longitudinal study of coronary heart disease. Circulution 28, 20-3 1 (1963). Percic, V., Stojsic, S., Hegedis, T., Ostrogonac, M. Serum transaminase activity in liver and biliary tract diseases. Amer. J. Gastroentrol. 45, 348-354 (1966). Ramcharan, S., Cutler, J. L., Feldman, R., Siegelaub, A. B., Campbell, B., Friedman, G. D., Dales, L. G. and Collen, M. F. Multiphasic checkup evaluation study. 2. Disability and chronic disease after seven years of multiphasic health checkups. Prev. Med. 2, 207-220 (1973). Stamler, J. High blood pressure in the United States. National Conference on High Blood Pressure Education, Report of Proceedings II, January, 1973. Trevelyan, H. Study to evaluate the effects of multiphasic screening within general practice in Britain: Design and method. Prev. Med. 2, 278-294 (1973). Williamson, E., and Van Peenen, H. J. Patient benefit in discovering occult hyperparathyroidism. Arch. Intern. Med. 133, 430-43 1 (1974). Zinner, S. H., and Kass, E. H. Long term (lo-14 years) follow-up of bacteriuria of pregnancy. N. Eng. J. Med. 285, 820-824 (1971).

III. B. HEALTH HAZARDS

Within the context of this report, those factors in the environment which constitute a risk to the health of an individual will be described as “health hazards.” Throughout human history, environmental health hazards have taken their toll of human lives. Even today, we read (1) that among the Navajo Indians accidents are the leading cause of death with falls (particularly falls from a horse) being the leading cause of accidents. With social and economic progress, a new and complex assortment of physical, mechanical, and chemical products and byproducts which are potentially hazardous to health have appeared. The increased risk may be to those engaged in manufacturing or processing the substances concerned, to the user thereof, or to the bystander.

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Primary prevention or the neutralization or elimination of cause can be approached in two ways. The first is for the local, state, or federal governments to set up and enforce regulatory standards to protect the community and individuals from the production, use, or indiscriminate disposal of hazardous materials. These include regulations against atmospheric and water pollution by industrial, agricultural and human wastes, food contamination and adulteration, noise and highway hazards and, for the industrial employee, adverse working conditions (Occupational Safety and Health Act 1970). The second is to minimize the effect of “human error” and this includes the education of the individual about personal protection against these hazards or their effect. Secondary prevention to minimize sequelae consists in early detection and treatment in the event of accidental trauma, chemical poisonings and so on. An example of this would be the detection of abnormal lead levels in the blood of children residing in dilapidated housing. What role can an HMO play in the prevention of accidents and intoxications among its enrollees when the cause is extrinsic and the patient is seen after the episode which is usually unpredictable? It has been estimated that there are many thousands of products in use in households which have been adjudged safe for use within limitations described on the label but which are decidedly dangerous if misused. Among these are found cleansing agents, bleaches, paints, solvents, lyes, corrosives, pesticides, over-the-counter and prescription drugs, cosmetics, and laxatives. There are also glass and metal utensils, toys, electrical equipment, carpets, furniture, staircases, hot stoves and pipes, hot water, infrared and ultraviolet lights. Experience has shown that health visitors can effectively reduce the risks in the homes they visit by education and demonstration (e.g., identifying defective cribs or poisons that are accessible to infants.) Training courses in first aid for responsible members of enrollee families in the event of traumatic or poison-related accidents can prevent excessive use of facilities for minor conditions and long disability, or death for major conditions which require immediate action. The HMO should have knowledge of and access to Community Poison Control Centers and inhalation and rescue squads, or else have available on its premises or in an affiliated hospital emergency medical facilities on a 24-hour basis to provide immediate care including blood or plasma, lavage, emergency surgery, etc. Physicians and other pertinent personnel should be kept abreast of new developments in toxicology and pharmacology relating to the effects of industrial, agricultural, and household poisons and adverse drug reactions of over-thecounter and prescription drugs. For those persons employed by large firms and during their period of employment, industrial physicians may be available to safeguard their occupational safety and health. Some industrial medical coverage may extend into the period of retirement. As a result, however, of the widespread internal migration of the population and the development and introduction of new industrial processes

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and chemicals, it frequently happens that delayed effects of hazardous substances are not associated with previous exposure. In addition, there are a large number of persons in small industry, farm workers and non-farm workers who never come under the care of an industrial physician. “It is estimated that three-quarters of the nation’s 75 million workers are employed in establishments with less than 500 employees. These comprise 99% of all the 4.7 million work places in the country. Almost with no exception, there is no organized preventive health program at these sites . . . not included in the preceding work force figures are the three million agricultural workers as well as hundreds of thousands of women hired for the most part on an hourly basis to perform a variety of household jobs” (2). This demonstrates that a majority of the American working force does not have the benefits of well-informed and trained occupational disease specialists. It is true that many have medical coverage provided through their employers, but this does not provide the same type of protection. For example, the Health Insurance Plan of New York City is a prepaid comprehensive plan for the employee, spouse, and dependent children fully paid by the employer who in this case is the City of New York. However, this plan does not provide for the prevention of accidental injury or trauma, radiation damage or poisoning, or assessment of such hazards at the place of work. It provides personal preventive services for the employees and their families without regard to potential hazards on the job. The effects of previous employment are not known except for a few serious diseases in which careful and dedicated epidemiological investigations have revealed an association. Examples are byssinosis among workers exposed to cotton dust; asbestosis and mesothelioma among asbestos workers; berylliosis among persons working with, residing near, or in contact with objects containing beryllium; pneumoconiosis among coal workers; lead poisoning among painters and lead battery workers, and mercury poisoning among workers using mercury. Recently angiosarcoma of the liver has been found among vinyl chloride workers. The association between aniline dye workers and bladder cancer was among the first such associations to be made. Since prevention consists in both the adherence to safety rules and regulations by the employer and the early detection and treatment of occupation-related illness or risk factors by the industrial physician, it follows that great numbers of employed persons even though protected by legislation on the job, in industry, agriculture and the services, are unable to benefit from the specialized supervision of the trained industrial physician. In these cases, it is logical that the HMO could fill this void. In order that the physician be aware of the hazards faced by persons at work, it is important that the enrollee complete a comprehensive work history questionnaire, both past and present. Thus, the early detection of suspicious findings can be correctly associated with potential cause. In addition, risk factors can be identified and the patient receive instruction and counseling about the hazards faced. For example, persons who have been exposed to asbestos and who smoke have a greater risk of developing cancer than those who do not smoke. There is another source of health hazards which has received little attention.

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These are those faced by persons with hobbies and independent professions such as those which require the use of paints, solvents, and glues. Thus, painting, modeling and making of airplane models may involve a health risk. Educational material and lectures about the correct handling of such materials can be made available to HMO populations. REFERENCES 1. Brown, R. C., Gurunanjappa, B. J., Hauk, R. J., and Bitsuie, D. The epidemiology of accidents among Navajo indians. Pub. He&h Rep. 85, 881 (1970). 2. Kerr, L. E. Occupational health-A discipline in search of a mission. Am. J. Pub. Heafth 63, 381-385 (1973).

III. C. THE NEED FOR HEALTH EDUCATION

“The need for health education within an organized system of health care is based on the fact that a person’s health status is highly dependent on actions taken by the individual independent of or in response to their experience in receiving medical treatment. This implies that if improved health status and

health maintenance are concerns of an organized system of care, there must exist within the system a sub-system designed to specifically deal with behavioral problems” (Internal Document. Puget Sound, April, 1973). The President’s Committee on Health Education (1973) reported: “Health education is a process that bridges the gap between health information and health practices. Health education motivates the person to take the information and do something with it -to keep himself healthier by avoiding actions that are harmful and by forming habits that are beneficial . . . Today . . . physicians and health educators are faced with new antagonists: diseases caused not by famine or contagion, but by aging, by our sedentary way of life, by nutritional excesses and dietary fads, by urbanization, by changes in the physical environments and by our mobile population . . . The needs of ethnic and minority groups for faster, easier, and cheaper access to the total health care system give health education the dual challenge of (1) educating those citizens to follow desirable personal health practices and (2) developing their ability to find and use the often bewildering array of services that is available . . . Helping to keep our morbidity and mortality rates stubbornly higher than they should be are . . . automobile accidents, dental and visual defects, . . . drug addiction, air pollution, the effects of crowded and sub-standard housing, emotional disorders and additional conditions . . . Many causes of disease and death can at least be influenced and some prevented altogether by good health practices by the individual. The fact is, however, that good health practices are not uniformly followed or even considered.” Health education cannot exist in isolation. Without correct health information, relevancy to the population being served and adequate facilities and opportunity to practice what is being taught, health education may serve very little purpose. The first number of “Health Education Report” (1973) describes the steps in health education in terms of the Scientific Method: the setting of goals, the definition of problems, the designing of plans, the conducting of activities and the evaluation of results. Ultimate goals are given as vigorous well-being, a reduc-

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tion in preventable disability and a reduction or delay in premature death. To get there, what is needed are: (i) appropriate personal practices; (ii) the prompt use of appropriate health services when needed; (iii) the carrying out of prescribed diagnostic and rehabilitation procedures; and (iv) broad effective participation in health program development. Education requires the effective, efficient, and appropriate application of what is known about how people learn. Positive or negative forces (determinants) influencing whether and how these goals can be achieved include heredity, physical environment, social conditions, health services, personal actions, values, goals, interests, pleasures, fears, attitudes, beliefs, perceptions, understandings, skills, habits, experience, cost, availability, laws, and environment. How and why people change their ideas has received considerable attention. This change can be thought of in terms of physical, intellectual and emotional involvement and trial, or in terms of the nature of the sensory input involved. In the bibliography’ will be found examples of each of these applied in general and to specific health problems which have become the subject of health education campaigns. Perhaps the most important of these relate to safety, cigarette smoking, and nutrition. There has been considerable contention over the years concerning who is best fitted to deliver health education programs. These differences of opinion are probably the single most important reason why health education programs have received less acceptance than they would appear to warrant. The professional (e.g., physician) engaged in health care delivery maintains that he is the only one who has the correct health information at his fingertips. The professional health educator (non-M.D.) maintains that the physician is not equipped to motivate persons to change their behavior. The community representative maintains that both professional groups previously mentioned are far too detached from the problems of the community they are serving. In terms of the magnitude of the task, it seems extremely unlikely that it can be covered by professionals alone. Most of the available literature on health education is concerned with the educational activities of health department and other governmental agencies, community health programs, voluntary agencies, and school health programs. Descriptions of the activities of special health education oriented professionals within prepaid group practices cannot readily be found. Preventive health-related activities which could be considered to be within the realm of health education whether administered by the physician, special health educator, nurse, or social worker include: 1. General health promotional activities related to appropriate personal health practices. Among these can be found: (a) personal cleanliness; (b) personal environmental sanitation (hygiene); (c) personal safety measures; (d) sex hygiene; (e) oral hygiene; (f) nutritional practices; (g) exercise patterns; (h) smoking patterns; (i) alcohol use; Cj) drug use; (k) food hygiene. 2. Health education dealing with the need for the prompt use of appropriate health services when indicated: (a) information relating to recognition of signs and symptoms which require immediate attention; (b) instruction concerning ’ To

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carwhich nutritional problems (e.g., those relating to certain metabolic, diovascular and hereditary disorders) should be referred to a professional nutritionist; (c) instruction concerning the need to obtain professional medical or psychological advice in breaking the smoking habit; (d) drug abuse clinics to change patterns of use of addictive substances including alcohol, barbituates, amphetamines, and other widely abused drugs. 3. Health educational activities in relation to special areas. Examples are: (a) immunization requirements; (b) premarital counseling; (c) family planning; (d) venereal disease prevention; (e) genetic counseling; (f) prenatal care; (g) infant care; (h) well-child care; (i) adolescent counseling; (j) mental health instruction; (k) geriatric counseling and instruction; (1) handling of hazardous substances, first aid in poisonings. 4. Educational support in the management of diagnosed chronic illness to prevent further breakdown. (a) the carrying out of prescribed diagnostic procedures; (b) the carrying out of rehabilitation procedures; (c) the management of emotional problems associated with several chronic illness; 5. Education of personnel in relation to the above-listed activities. This may appear to be an imposing list. However, when carefully analyzed, it will be found that the physician, nurse, nutritionist, physical therapist, etc., do provide pertinent health education where needed. However, it is time consuming and, wherever possible, could be covered by specially trained professionals. In the absence of such professionals, and with a lack of funds to purchase pertinent visual aids and literature, provision should be made to utilize health departments, community programs, voluntary agencies, and boards of education to provide such instruction. The planning and implementation of a health education program cannot be solely dependent on the professional and financial resources immediately available within the HMO. The knowledge, skills and time of other members of the HMOs consumer and professional community will be continually required. At times, it may be helpful, or even necessary, to seek human and monetary resources “outside” of the group. Furthermore, significant attention should be given to the education and training of a cadre of consumer volunteers to assist in administering educational activities (Internal Document, Puget Sound, April 1973).

No health education program is complete without some attempt at evaluating what it has achieved. It is not enough to evaluate process alone. Health education is only successful insofar as it changes the behavior of the people being addressed and ultimately benefits their health. REFERENCES 1. Schoenrich, E. H. The potential of health education in health services delivery. Maryland Workshop of Patient Education. Health Services Rep. Jan.-Feb. 1974, Vol. 89, No. 1, p. 3-7. 2. The Report of the President’s Committee on Health Education. Health education is a process that bridges the gap between health information and health practices. p. 12, New York City, 1973.

III. D. CHRONIC DISEASE PREVENTION

In the United States, as elsewhere, dramatic reductions have been achieved since 1900, and indeed since 1940, in infant and maternal mortality rates and in deaths between 1 and 10 years of age. In contrast, very little has been achieved

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in increasing the life expectancy of a man who has already reached the age of 40 years. Over 75% of all deaths today in the United States are due to a so-called chronic disease. With our present knowledge, and based on the experience of the Seventh Day Adventists and other special groups it can be stated with certainty that the average life expectancy of males in the United States can be extended by 7 to 9 years if our present knowledge concerning the prevention of chronic diseases is fully applied. Those chronic diseases that lend themselves most clearly to prevention (or a shift to a later age period) are coronary artery disease, hypertension and its complications (including stroke), rheumatic heart disease, certain forms of cancer (lung, breast, cervix, and possibly colon), aid cirrhosis of the liver. For other chronic diseases such as diabetes and cholelithiasis some improvement is possible. Prevention of other nonfatal but crippling disease (or early amelioration of these conditions) such as glaucoma, certain forms of anemia, and arthritis can make life much more worth living. The prevention of mortality and morbidity arising from these chronic diseases involves: (a) The recognition and support of established primary preventive measures. (b) The identification and listing for follow-up of persons with early abnormalities. (c) The appropriate correction and long-term follow-up of early disease that has been found. The best means of primary prevention is undoubtedly common sense living as recommended by the American Heart Association and followed by many Seventh Day Adventists and other substantial population groups in this country as well as overseas. This sensible living involves the avoidance of tobacco (and in particular of cigarette smoking) and a prudent diet. This prudent diet is one where some 30-35% of calories only are obtained from fats, the intake of saturated fat and cholesterol (such as eggs) is reduced until the polysaturated-saturated ratio is about one and the total caloric intake is sufficiently limited to avoid obesity while insuring an adequate vitamin and iron content. Together with these two simple measures an adequate amount of physicial exercise exerts an indirect ripple action, increasing pride in the body and making life more stimulating. To prevent rheumatic heart disease a program is needed for the early and effective treatment of streptococcal infections. In specific population groups, such as pregnant women, dietary supplements such as folic acid may be indicated. A number of diseases lend themselves to early diagnosis so that effective early curative and preventive measures can be undertaken. Thus, anyone who has had an attack of rheumatic fever or rheumatic heart disease should be protected by oral penicillin against the risk of further attacks with possible permanent heart damage ensuing. A diastolic blood pressure of greater than 100 is an indication for continued appropriate therapy. A diastolic blood pressure between 90 and 100 demands observation, weight loss, salt restriction and careful reconsideration from time to time. A serum cholesterol above 220 in a male is an indication for some limit being set in the intake of saturated fats and cholesterol.

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Breast examinations for suspicious lumps, mammography, thermography, “Pap” smears, rectal examination, guaiac tests on prepared patients, and possibly proctoscopies, together with a high index of suspicion will lead to the diagnosis of many cancers in an early and substantially curable stage. Microcytic anemias in older persons should lead to the suspicion of bowel cancer. A raised intraocular pressure and a raised blood sugar can lead to a suspicion of glaucoma or diabetes, respectively, though both of these diagnoses must be very carefully checked before long term intervention is undertaken. All of the above screening procedures should form a routine part of the medical care of any adult seen in any medical setting and it is to be hoped that at least once a year every adult seen at an HMO will have at least this list of screening procedures attended to even if it is not done as part of a specifically designed screen. Screening procedures are useless if they are not associated with an intensive and careful treatment and follow-up program. Every medical care system should have some arrangement whereby persons with chronic disease such as hypertension are flagged so that a close touch can be kept on them to insure that treatment is continued. Experience has shown that with hypertensive patients, intensive follow-up can increase the percentage kept under treatment for a l-year period from under 20% to over 90%. It is only when this last level is obtained that these major and readily remediable causes of death can be controlled in our society. To increase the yield and cost effectiveness of any program directed at the prevention of chronic disease it is necessary that the preventive intervention be particularly targeted at populations known to be at higher-than-average risk from the particular disease under consideration. Thus, there is suggestive evidence (2) that a population of women with an early first pregnancy and antibodies to HSV-2 antigens can be identified which stands a greatly increased chance of developing cancer of the uterine cervix. For this population it would be particularly important to maintain close supervision through repeated Pap smears. Similarly, for males with a guaiac-positive stool test after suitable preparation (l), proctoscopy and a detailed work-up for large-bowel disease may lead to the early diagnosis of surgically curable colon cancer. Where diseases are sufficiently common either nationally (e.g., hypertension) or in a particular community (e.g., lead poisoning in inner cities) this prescreening may not be required. For occupation or work-related diseases (dealt with elsewhere in this report) the classical question “What is your job?” followed by an appropriate review may be of great help in protecting against such conditions as osteoarthritis, dermatitis, and pneumoconiosis. When one realizes that those chronic diseases whose onset can fairly readily be postponed for 10 years or more by simple preventive measures account for more than half of all major disability, of all hospital days and of all deaths in the age group under 70 years, it becomes apparent that every health maintenance organization could materially benefit the community it serves by advocating these simple preventive measures.2 ’ For those persons identified as being at particular risk, the necessary therapeutic support needs to be provided.

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REFERENCES 1. Greegor, D. H. Occult blood testing for detection of asymptomatic colon cancer. Cancer 28, 131-134 (1971). 2. Nahmias, A. J., Naib, Z. M., and Josey, W. E. Epidemiological studies relating genital herpetic infection to cervical carcinoma. Cancer Res. 3, 111 l-l 117 (1974).

III. E. THE MATERNITY

CYCLE AND THE NEONATE

How can an HMO assure that the best preventive strategies are provided for all women of child-bearing age enrolled in their program so that a minimum of maternal and fetal loss is sustained and regional ethnic and socioeconomic differences are erased? Such a program should assure that there be provisions for: 1. 2. 3. 4. 5.

6. 7. 8. 9.

Premarital examinations and counseling. Reproductive and genetic counseling. Family planning services. Comprehensive prenatal care. Delivery by interested qualified personnel in good surroundings with readily available complete services for dealing with any emergency that might arise. Preventive services for the neonate and infant including home visiting services as necessary. Provision for dealing with any medical emergencies that might arise and maternal education in using medical services. Follow-up on the mother. Provision for continuing evaluation of available services and programs.

The first three items assume that the prospective parents belong to the same HMO group and will have indicated to their physician their desire to get married. This should be among the services publicized under health education. A prospective partner who is not a member of the group should be asked for the desired information and take the necessary tests. I. Premarital examinations and counseling. A. The prospective marital partners should be tested for venereal disease. B. The woman should be tested for the Rh factor and if she is negative, the man tested as well. C. The rubella immune status of the woman should be measured. D. The medical and family history of the enrollee should be completed and evaluated for medical or genetic risks. In each case, dependent on the funding, appropriate counseling and treatment should be undertaken. II. Reproductive and genetic counseling. For the patient who is contemplating the possibility of becoming pregnant, appropriate measures include: A. The medical history should be examined for information about genetic defects and previous pregnancies, especially about difficulties encountered and outcomes of pregnancy. B. A physical examination should be performed. All examinations requiring X-rays should be conducted before conception takes place. C. Treatable infectious diseases such as tuberculosis, the veneral diseases, and urinary tract infections should be sought and treated if found. D. The nutritional

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status of the patient should be established. E. A blood glucose determination is of value for comparison with values obtained at prenatal examinations. If frank diabetes is detected, a detailed work-up is required and pregnancy may be contraindicated. F. If there is a history of tetanus neonatorum in the HMO region and population served, the tetanus immunization status of the prospective gravida should be elicited. Immunization should be provided if not immune. G. A general educational program should be provided for the pregravida. This should relate to nutrition, hygiene, smoking, and alcohol consumption and the use or misuse of drugs. A review of all prescribed and over-the-counter drugs which the patient is currently using should be made and the patient be given careful instructions about their discontinuance or continued use. Known teratogenic drugs should be discontinued. III. Family planning services. Family planning programs should take into consideration the religious and cultural tenets of enrollees and legal restrictions applicable to the community being served. Subject to this, available services should include birth control instruction and materials as well as voluntary sterilization and abortion when requested. Family planning services are preventive in that they aid in averting the indirect ill effects of unwanted pregnancies. Criminal abortions accompanied by lethal or pathological outcomes, suicides, infanticides, the battered child syndrome, juvenile delinquency, and other behavioral problems may be the outcome of unwanted pregnancies. Family planning services should be made available to adult men and women and to sexually active adolescents on request. If not available directly through the HMO, provisions should be made for referral to a local unit of a family planning or planned parenthood agency. Voluntary sterilization of males and females should be provided if not prohibited by the law of the state. IV. Comprehensive prenatal care. In an extensive study by the National Health Survey (3), prenatal care is defined as at least one visit for medical care and ranges from a low of one doctor visit in the third trimester of pregnancy to as many as four or more beginning with the first trimester. Prenatal care is adequately covered in the standard obstetrical textbooks. The preventive elements of this care include: (1,2) A. At least three medical examinations, beginning with the first suspicion of pregnancy and including as appropriate: 1. A medical and family history. 2. Measurements for blood pressure, weight, hemoglobin, albuminuria, glycosuria, bacteriuria, blood grouping, and Rh factor determination. 3. Special examinations for syphilis, gonorrhea, and tuberculosis. 4. Physical examination including an estimate of pelvic adequacy and with particular attention to the genitourinary and cardiovascular systems. 5. Amniocentesis if required by virtue of age of mother or genetic family history (only if patient will agree to abortion). 6. A measurement of nutritional state. 7. An assessment of emotional state. B. Special attention to the high risk mother and corrective action if possible. High risk mothers include the older patient; the very young; the unwed; adoles-

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cent; primigravida; women with a previous history of complications such as premature delivery, toxemia, eclampsia; Rh sensitization; those who are seriously underweight or overweight; those suffering from tuberculosis, diabetes, hypertension, rheumatic heart or other cardiovascular ailment; those with a history of drug addiction or alcoholism; and the physically malformed, disabled, and mentally subnormal. C. Avoidance of irradiation of the pelvic area. D. Caution in use of hormonal, antithyroid, and antihypertensive drugs, especially those with known teratogenic effects. E. Admonition against the careless use of over-the-counter drugs such as laxatives, analgesics, antacids. F. Avoidance or limitation of alcohol, tobacco, sleeping pills, sedatives, and addicting drugs. G. Avoidance of hazardous occupations or other activities. H. Classes for expectant parents. I. An assessment (where appropriate) of home conditions that might constitute a particular risk for the new baby including the measurement of metal leaks in water supplies of areas where methemoglobinemia is a problem. V. The delivery. Delivery by interested qualified personnel in good surroundings is the right of every woman and the HMO should provide such services or be affiliated with an institution that can. The rules and guidelines for good obstetrical care are generally known. As a minimum, facilities should exist (personnel, ability to provide anesthesia and resuscitation, transfusion requirements, etc.) on a 24-hr basis for dealing with any emergencies that may arise. Heavy sedatives are generally contraindicated. VZ. Preventive services for the neonate. Under the conditions of an HMO a team of specialists is available to pool their expertise. The pediatrician and his support personnel have an important role to play. Preventive health care for the neonate includes: A. Avoidance of infection, specifically ophthalmia neonatorum, by installation of silver nitrate or suitable antibiotics into the eyes. B. Complete visual and physical examination of the baby to detect congenital anomalies, visible or internal, which may be amenable to correction. C. The avoidance of oxygen for premature infants unless essential. D. Determining inborn errors of metabolism when possible and instituting corrective therapy. E. Looking for and treating drug-withdrawal symptoms. F. Protection against nursery infections of the skin or gastrointestinal tract. I/II. Care of the mother. The postpartum patient should be followed-up approximately 6 wk after delivery for evidence of any remedial conditions. At this time, an interval history should be taken and the new mother’s medical condition reviewed. The cervix should be viewed for evidence of infection or erosion and the breasts should be examined for cysts and nipple fissures. She should be given instructions for exercise to restore her figure, dietary counseling, and if warranted, instruction and materials for family planning. The status of her mental and emotional health should also be evaluated.

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REFERENCES 1. Buch, C. W. Prenatal and perinatal causes of early defects and deaths. in “Preventive Medicine” (D. Clark and B. MacMahon, Eds.), Chap. 9, Little Brown, Boston, 1967. 2. Schlesinger, E. R. The maternity cycle and the newborn period. in “Preventive Medicine”, Chap. 24 (H. Hilleboe and G. W. Larimore, Ed%), W. B. Saunders, Philadelphia, 1965. 3. U.S.D.H.E.W. Vital and Health Statistics. Series II, No. 125. Prenatal-postnatal health needs and medical care of children. U.S. Gov’t Printing Office, Washington, D.C. April (1973).

III. F. CHILDHOOD AND ADOLESCENCE

According to Velder (I), preventive pediatrics is the application of that body of knowledge which will “enable the child to be well born, to come into the world strong and healthy, to thrive lustily and without halt during infancy, to grow and develop in a normal way during childhood, to be able physically and mentally to acquire a sound education, to acquire good habits of living and to avoid bad ones, to avoid psychological abnormalities so that the child adjusts himself through the difficult period of puberty and adolescence into a sound normal maturity, to prevent ill health by maintenance of good health, to prevent by scientific measures, so far as we are able, the infectious diseases of childhood.” A. Infant and preschool children. Preventive services for this age group should include: 1. A detailed medical history, linked to the mother’s familial medical prenatal and delivery history, periodically updated. 2. Selected anthropropometric examinations, e.g., height, weight, head measurements, abnormalities of structure, etc. 3. Selected laboratory examinations during infancy and periodically thereafter, e.g., hematocrit, red blood count, white blood count, sickle cell test when indicated, urine microscopic for presence of RBC bacteria, glucose, and protein, lead levels where indicated, etc. 4. Selected physical examinations as soon as required and periodically thereafter, adding new ones as indicated. These include vision, hearing, speech development, muscular coordination, growth and maturation, etc. 5. Routine immunizations for pertussis, diptheria, tetanus, poliomyelitis, measles, rubella and mumps (males only). 6. Tuberculin testing should be performed on children at high risk of contracting the infection from family or community contacts. 7. Parents should be counseled about child-rearing practices, especially in the area of nutrition, feeding patterns, cleanliness, and early recognition of signs and symptoms requiring medical attention, especially the potentially hazardous communicable diseases. They should be informed about the dangers of automobile and home accidents and poisons and what to do in an emergency. They should be warned of the danger of reliance on home and folk remedies, and the need for periodic examinations and immunizations should be stressed. Conditions which affect the young and the effect of which can be minimized by appropriate preventive care, include feeding and nutritional problems, malnutrition, iron deficiency anemia, strabismus and other visual problems, hearing defects, speech defects due to structural and other causes, neurological defects,

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genetic and congenital defects such as some inborn errors of metabolism, and congenital dislocation of the hip, retarded intellectual and physical development, musculoskeletal defects, cardiovascular problems, dental problems, emotional and behavioral problems, evidence of child abuse or neglect and infections such as measles and pyelitis. B. School age children. The provision of preventive services for children should not cease at age 6 or 7. Further problems may either develop or pass early detection. To make provisions for these: 1. The medical record should be kept up to date and any untoward developments or risks noted and treated. 2. Parents of children who are absent from school for medical reasons should be encouraged to bring them in for examination and if the condition warrants preventive or follow-up action, it should be provided. For example, a child with a hemolytic streptococcal infection should be followed to determine whether or not known sequelae such as acute glomerulonephritis, rheumatic heart disease, chorea, or otitis media can be prevented or have already occurred. 3. Periodic anthropometric, physical and laboratory examinations should be administered at appropriate intervals. These could reveal new or previously undetected conditions such as anemia, hyperglycemia, musculoskeletal disorders, malnutrition, obesity, sexual immaturity, hormonal defects, cardiovascular problems, epilepsy, visual, hearing, intellectual impairment, speech and communicative disorders, emotional or behavioral maladjustments. 4. Immunization status should be reviewed and updated with boosters where required and initial immunization given where deficient. 5. Special attention should be given to children at high risk of contracting parasitic diseases, tuberculosis, lead poisoning, drug or alcohol abuse, etc., due to their geographic, social, economic, or familial environments. 6. Education and counseling of parents and children should be provided. C. Adolescents (youths 12-Z 7 years of age). This age group is usually reluctant to seek medical attention or follow advice about healthful living habits, but it is at this age that a number of adult health problems originate. Provision should be made for the detection of those medical, physical, and emotional problems afflicting the adolescent which are either preventable or amenable to intervention. These include malnutrition (including underweight and overweight), acne, dental caries, malocclusions, visual defects, hearing defects, organic heart disease, epilepsy, diabetes, musculoskeletal abnormalities, sexual immaturity, emotional and behavioral maladjustment, smoking, drinking and drug abuse, tuberculosis, syphilis, and gonorrhea. Preventive examinations should be geared toward these problems but should also include some screening examinations which may detect subclinical signs and symptoms of “adult disease.” 1. If the adolescent enrollee is new and does not have a detailed history, this is the time to initiate one. This could include smoking, drinking, and drug use behavior. 2. Anthropometric examinations including height, weight, skin fold thickness, and other body measurements should be made. 3. The physical examination should include the possible effect on growth and

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development of previous illness, susceptibility to accidents or injuries, the presence, distribution and severity of acne, and evidence of scoliosis or other musculoskeletal deformities. 4. There should be tests to detect visual and hearing performance, motor coordination and speech impediments. The blood pressure should be taken. 5. Blood samples should be examined for glucose and cholesterol. Tests for such substances as protein-bound iron and lead may be indicated under special circumstances. 6. An evaluation of immunization status should be made with boosters given when indicated, and initial immunizations provided when needed, e.g., tetanus, poliomyelitis. 7. Under certain special circumstances, additional tests such as an EKG and phonogram (for congenital heart defect screening) or X-rays of the chest, hand, and wrist may be indicated. 8. A dental examination for status of deciduous and permanent teeth, missing teeth requiring replacement, assessment of occlusion, bite, gingivitis, periodontal disease, and oral hygiene should be provided. 9. Tests for pregnancy may be indicated. 10. An evaluation of emotional and psychological status should be made, including antisocial behavior, patterns of alcohol, tobacco, drug use, and sexual patterns. 11. The following services should be made available: (a) health education in relation to oral and personal hygiene, use of alcohol, drugs, sex hygiene, venereal disease, nutrition, accident control; (b) individual counseling in relation to physical growth and sexual maturation; (c) correction of visual and hearing defects; (d) birth control instruction and abortion services when requested (without parental consent if appropriate in the context of the individual patient). REFERENCE I. Velder,

B. S., “Preventive

Pediatrics”,

Vol.

II (R. S. Hayner,

III. G. MENTAL

Ed.),

Appleton,

New

York,

1926.

HEALTH

The expression “good mental and emotional health” is usually understood to denote the ability of an individual to conform to expected moral and social norms of intrapersonal or group behavior. This may be measured positively in terms of scholastic aptitude, ability to be self-sufficient and self-supporting, the ability to refrain from violence to oneself and others, ability to be responsive to the family and community or ability to enjoy oneself. It may be measured negatively in terms of freedom from disturbances in the state of mind (mood), mental processes, or awareness (perception), or by the absence of abnormal or antisocial behavior. Inability to conform to these norms constitutes mental illness. Mental illness (1) is a catch-ah classification which characterizes a common symptom, i.e., a degree of mental or emotional disability. Disability may range from slight manifestations of mild neurotic disorders, such as fear of heights, to the permanent disability of a serious psychosis requiring long-term hospitalization.

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The disability of the mentally subnormal resulting from incomplete mental development also covers a wide variety of manifestations, from a borderline IQ to the helplessness of the severely brain damaged. The causative factors in some mental illness involve diverse agents which may be genetic (genes and chromosomes), chemical (poisons, drugs, oxygen deprivation, etc.), infections (syphilis, toxoplasmosis, meningococcal meningitis), physical, traumatic, or psychogenic. Many mental disorders have as yet no known or detectable causes. Prevention of those mental illnesses for which the causative agents have been found has shown some dramatic results. Examples are the virtual disappearance of new cases of syphilitic psychosis (paresis) as a result of the availability of early diagnosis and treatment, and a similar disappearance of the psychosis associated with pellagra since its nutritional basis was clarified. Progress is also associated with a better understanding of erythroblastosis foetalis, PKU, galactosemia and other genetic and chromosomal defects, immunization against rubella, the relationship between congenital problems and maternal malnutrition, the misuse of drugs, the importance of prematurity and the need to avoid unnecessary radiation. Immunization of children against measles and antibiotic therapy for meningococcal meningitis are also important in the prevention of mental illness. The mental damage wrought by chronic alcoholism, the hallucinogenic and psychotropic drugs and the barbiturates are recognized. For their part, prevention calls for the initial treatment of the underlying causes, social, environmental, medical or psychiatric. The promotion of the general mental health of the enrollee by aiding in the development of a “strong personality” is a factor in the prevention of personality disorders. The personnel of an HMO should be taught to differentiate between individual and cultural differences of enrollees when interpreting or evaluating so-called abnormal and unfamiliar behavior. A health education program (2) conducted by educators, mental health workers, and physicians for the enrollees could contain: (a) instruction relating to mental health in general and its impact on the overall well being of an individual. Specific attention should be placed on the abuse of alcohol and other addictive substances. (b) instruction and counseling of potential parents about prenatal and postnatal hazards which could affect the unborn child. (c) instruction and counseling of the family of the mentally ill or mentally subnormal. (d) instruction and counseling in the case of the return of a mental patient into a family. (e) counseling in the case of severe bereavement and loss of employment, failure in school, divorce, etc. (f) counseling of the geriatric enrollees to prevent breakdown and to provide reassurance on physical health, nutritional instruction and referral to agencies which help in improving home environment, provide interests and prevent suicide.

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(g) instruction and counseling directed at fostering healthy living, e.g., parentchild relationships, marriage and the family, stress. (h) special courses for adolescents in sexual development and hygiene to prevent emotional disturbances. (i) possibly instruction and counseling on financial and interpersonal problems. In the event that such services are not available, assistance for supplying literature, lecturers or counselers should be sought at local mental health centers, clinics, or hospitals. Secondary prevention would consist of the early detection and treatment of early signs and symptoms of mental and emotional illness to prevent further breakdown. A major concern of the mental health professional is the prevention of unnecessary disability and death resulting from suicide. Depressive mental illness is frequently a cause of suicide. The physician has a great responsibility to recognize and to evaluate the seriousness of all depressive states. If the risk is considered substantial, the physician should seriously consider hospitalization. Clues which point to a suicidal tendency and should be watched for include previous attempts at suicide, depression marked by somatic complaints, sudden recovery from depression, endogenous depression with delusions and hallucinations, barbiturate addiction, hysteria and suggestibility, and identification with a deceased person. Elderly persons present special problems. Any indication of depression must be recognized and the condition treated. The need for the medical community to become involved in detecting and treating suicide-prone individuals is vital. Most of the literature relating to suicide prevention is concerned with suicide prevention centers which exist separately from a person’s primary source of medical care. Their function is to deter an overt suicide attempt and to give some support in preventing another incident. However, a few articles provide some suggestions as to the role of the physician in detecting and treating the suicide-prone individual, even before there has been any self-destruction attempt. The strategy of suicide prevention in an HMO might have two components: (i) The availability of a referral service at the Center on a 24-hour basis to provide assistance to the HMO enrollee who phones for help in averting a suicide attempt and (ii) The early detection of a suicide-prone individual by the personal physician and referral for psychiatric assistance. REFERENCES I. Commission on Chronic Illnesses. Mental illness, in “Chronic Illness in the U.S.A.“, Chap. 17. Commonwealth Fund, Harvard University Press, Cambridge, Massachusetts, 2. Goldston, S. E. Mental Health Education in a Community Mental Health Center, Amer. Heolrh. 58, 693 (1968).

III. H. DRUG ABUSE

Vol. I, 1957. J. pub/.

AND ALCOHOLISM

Drugs or substances which when taken into the living organism may modify one of its functions, are considered acceptable when used for therapeutic pur-

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poses. The same drugs, when utilized for other than therapeutic purposes, are often found morally, medically, and socially unacceptable. The WHO Expert Committee on Drug Dependence provides definitions which distinguish between drug abuse and drug dependence and which provide the basis for approaches to prevention. Drug abuse is “persistent or sporadic excessive drug use inconsistent with, or unrelated to, acceptable medical practice.” The drugs which fall under this definition include opiates, synthetic opiate derivatives and opiate-like drugs, amphetamines, psychotropic agents, cocaine, tranquilizers, hypnotics, and occasionally solvents which have not been prescribed for therapeutic purposes. Drug dependence, on the other hand, is a “state, psychic and sometimes also physical, resulting from the interaction between a living organism and a drug characterized by behavioral and other responses that always include a compulsion to take the drug on a continuous or periodic basis in order to experience its psychic effects and sometimes to avoid the discomfort of its absence. Tolerance may or may not be present. A person may be dependent on more than one drug.” The drugs which are dependence producing include most of the categories named above, i.e., the opiates, barbituates, amphetamines, and tranquilizers, with the difference that they may have been at one time prescribed for the patient for therapeutic purposes. Some patients develop a psychic and physical craving for the drug even after the original need has passed. These patients will do all they can to get supplies of the drug. Primary prevention of drug abuse is chiefly a community problem, especially if the drug under consideration has the effect of creating behavioral or other responses which could result in physical, social, or economic consequences to the user and others. Research related to the approaches to primary prevention of drug abuse is in progress, but conclusions about applicability are still not available. If the abuse depends on illegal acquisition of the drug, there are specific local, national, and international measures aimed at its prevention. If, however, it relates to the abuse of a very common household, community and industrial product, such as in glue sniffing, there is little that can be done except to label the container, perhaps modify the product, and try an educational approach in school. Since the best prevention would be to avoid the use of any of these nonessential addicting drugs, the target population for prevention is the youth where temptations to try new sensations and peer pressures are greatest. Various educational approaches are being tried. Secondary prevention or early detection and intervention may be more applicable. Physicians and other personnel involved with school- and college-age enrollees should be alert to signs and symptoms known to be associated with drug abuse, and either provide intervention services and counseling or make referrals to community agencies responsible for supplying preventive services without considering drug abuse a moral or criminal offense. Urine tests can be conducted as part of the physical examination when such abuse is suspected. Drug dependence, on the other hand, does provide an opportunity for the HMO to become involved in primary prevention. In this situation, it is usually a

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drug which has been prescribed for a specific therapeutic purpose to which the patient has become dependent. Physicians and ancillary personnel should be fully aware of the hazards of dependence-producing drugs and should be judicious in their prescription and dispensing. Many drugs now carry labels warning of dependence. There are approximately 100 narcotic drugs on the International List and many non-narcotic drugs know.n to produce dependence with deleterious cumulative effects. The patient should be warned of the dependence-producing quality of these drugs as well as their proper dosage. Issuance of repeat prescriptions should not be perfunctory. Pharmacists should be asked to keep careful records of patients’ purchases and if the patient is in danger of overutilization, it might be possible for the physician to prescribe a similarly acting drug with a lower-dependence liability or a placebo to wean them of the dependence. Alcoholism may be considered a special case of drug abuse. When confronted with the question of preventive strategies which could be used by an HMO in relation to the problem of alcoholism, we are faced with a dilemma. Although the symptoms resulting from the chronic or habitual ingestion of toxic amounts of alcohol give the name to the disease, the most important of the causative factors appear to be within the host. It is speculated that the personality of the alcoholic and the social and environmental environment play the greater role, and that if alcohol were not available, some other product with similar effects would be substituted; e.g., heroin addicts frequently have an alcohol problem as well. Alcohol consumption is an acceptable medical and social practice in our culture. When this consumption gets out of control and becomes a compulsion, alcoholism results. Primary prevention, or an indoctrination of a sensible approach to the use of hazardous substances including alcohol, is recommended as part of grade and high school health programs. The success of such an educational effort has yet to be documented and can only be evaluated after long-term follow-up. However, this does not mean that it should not be continued. Where it is not included in the local school curriculum, the HMO could include it as part of the educational services provided for the inculcation of healthy living habits to the parents of children and adolescent enrollees and to the children and adolescents themselves. Lectures by specialists utilizing slides, visual aids, and literature provided by local and national agencies, both governmental and voluntary, could be conducted. Among the high risk groups can be found children of alcoholics where environmental influences may be strong. They should receive special attention, especially educational counseling. Secondary prevention, early detection and prompt attention to the problem might be more successful. Instead of waiting for the end results, such as cirrhosis, acute and chronic brain syndrome, gastritis, anemia, pancreatitis, and other outcomes of chronic alcoholism, the physician should begin to treat alcoholism at a time when intervention might have a positive effect. Alcoholism should be treated as any other disease over which the patient has little control. Inclusion of questions in the medical and follow-up histories could

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elicit information which would indicate when a change in drinking patterns has occurred and the patient is on the verge of slipping from social to habitual drinking. It is estimated that some 9 million of the 95 million drinking adults in our country are either alcoholics or potential alcoholics; therefore, the physician should be alert to those early signs and symptoms of physical and psychological change which accompany alcoholism in order to provide counsel to the patient and family about preventing further breakdown by trying to correct the problem. The patient in danger of, or suspected of suffering from alcohol damage should be evaluated to determine what preventive services could be supplied to retard the process. Evaluation should be provided from a medical, psychiatric, neurological, social, psychological, and educational viewpoint. Treatment services in a properly staffed and equipped facility, including alcohol detoxification, chemotherapy, medical-surgical services, should be made available. Individual or group discussions with regard to the use, abuse, and effect of alcohol upon the body, mind, family, job, and society of the alcoholic should be fostered. If these are not available or feasible in the HMO, arrangements should be made to use a special alcoholism treatment facility provided by the closest hospital or agency which may well be Alcoholics Anonymous or other nonprofessional group. Special efforts should be directed at the pregnant alcoholic to prevent the fetal alcohol syndrome which includes growth deficiency, low IQ, developmental delay, etc. The effect of alcohol on the fetus of the nonalcoholic social drinking mother has not yet been studied. Of the chronic alcoholics in this country, two million are women, and among these, half are of child-bearing age. Special educational efforts should be directed at drivers of automobiles and other motorpowered vehicles. In New York State alone, in 197 1, there were 3227 motor vehicle accidents which involved fatalities, of which 50% could be attributed to persons who had been drinking heavily. Special attention should be paid to hazards of suicide in the alcoholic population. Various studies appear to indicate a relationship between suicide, attempted or suspected, and suspicious accidental deaths and alcohol, although precise data are not available. III. I. PREVENTIVE

DENTISTRY

Dental disease and disability is one of the nation’s most prevalent health problems. No other illness, except perhaps the common cold, affects as many lives. Over 95% of the U. S. population is currently suffering from or has experienced some form of dental disease (particularly dental caries and/or periodontal disease). The Health Interview Survey found that during 1969, about 45% of the civilian noninstitutional population of the United States made at least one dental visit during the year prior to the week of the interview (1). Dental diseases are usually chronic. They compound and form a backlog of needed treatment which generally involves expensive and time-consuming professional care. Despite the fact that in 1972 more than 5 billion dollars, or about 9% of all health care expenditures, were for payment of dental services, it is es-

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timated that over 20 million Americans are completely edentulous and another 90 million are partially so. In addition, there are an estimated 127 million teeth with unfilled dental caries. Because of the irreversibility of most dental disease, prevention at a very early state prior to its initiation is crucial. The importance of dental health has been underscored by recent evidence, both clinical and experimental, that dental disease and abnormalities have a direct and detrimental impact on general health. Healthy teeth and proper oral structure are important for speech, mastication, and deglutition, and appearance, assisting both physical and psychosocial well-being. The American Dental Association’s Council on Dental Health offers the following definition of preventive dentistry: “ . . . procedures in dental practice and dental health programs which prevent the occurrence of oral diseases. Included in the range of preventive procedures are oral prophylaxis, topical application of fluoride dentifrices, oral cytology, patient education, including home care, and other techniques.” In the past, dentists were primarily craftsmen restoring damaged mouths and patching teeth until there were no teeth left to fix. For the past 30 yr, evidence has been available that fluorine is effective in fighting tooth decay, and estimates have been made that 65% of all decay could be prevented if every child would drink properly fluoridated water and use fluoride dentifrices. However, even today, fluoridation and fluoride application are not universal in the United States. Dentists are currently widely accepted as part of the health team, sharing the responsibility for screening well patients who are not yet aware of their need for treatment. Given adequate support and utilization, it is now possible to reduce the incidence of some preventable dental disease and to treat that which does occur. The National Caries Program at the National Institute of Dental Research is the focal point for research in the United States in the prevention of oral disease. They have been supporting basic and applied research in four major areas outlined by N.I.D.R. as follows: (1) methods to increase the resistance of the tooth, (2) methods to interfere with caries-causing oral bacteria, (3) methods to alter harmful ingredients of human diets, and (4) methods to improve the delivery of preventive agents and techniques and their acceptance by the public. Among preventive services currently provided by community children’s dental clinics are included: (1) examinations for evidence of caries; (2) examinations for malocclusion, jaw dislocation, and other structural abnormalities; (3) application of topical fluorides; (4) provision of fillings and other restorative services; (5) oral prophylaxis; (6) provision of dental health education to children and parents in brushing, flossing, and nutritional counseling. REFERENCE 1. Vital and Health Statistics. States1969. U.S. Dept. No. 76 (1972).

Dental of Health,

Visits. Volume and Interval Since Last Visit. United Education, and Welfare. Rockville, Maryland. Series lo,

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IV. PREVENTIVE HEALTH CARE BENEFITS BY EXISTING HMO PROTOTYPES

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PROVIDED

Consideration has been given to having certain preventive health services incorporated into the HMO benefits package including (a) voluntary family planning services, (b) infertility services, and (c) preventive dental care for children, (d) children’s eye examinations to determine the need for vision correction, (e) health education, and (f) immunizations. Supplemental benefits suggested which have been recommended include (g) treatment of psychiatric conditions, (h) treatment of chronic alcoholism, and (i) drug addiction, as well as (j) dental care and dental X-rays. Other preventive benefits currently being provided by HMOS include (k) initial health screenings, (1) health hazards appraisal, (m) periodic examinations, (n) self-administered health history questionnaires, (0) genetic counseling, (p) prenatal services, (q) well baby services, (r) and (s) developmental exams (speech and hearing), (t) psychiatric, psychological testing, and (u) suicide treatment and prevention services. Using the HSA Health Maintenance Organization - Organization Program Status Report -June 30, 1973, a sample of 50 HMO prototypes was selected. The sample included a number of long-established plans as well as a group of newer HMO’s initiated by HEW and supported by grants and contracts, plus a number of other “HMO-like” organizations. The plans contacted were scattered from coast to coast and provided for communities from the northern to the southernmost borders of the USA. They had diverse catchment populations with enrollments ranging from over a million to only a few hundred. The socioeconomic characteristics of the surveyed populations were also very diverse. All initial contacts were made by telephone. In most instances, it was the plan administrator or his representative who answered the inquiry. After explaining the purpose of the study, each plan representative was asked to respond to a loto 15-minute telephone survey (questions listed at the end of section). At the end of each interview, the health agency was requested to forward a copy of its membership brochure or any other descriptive material (70% of those sampled complied with this request). Of the 50 prototypes in the sample, one was no longer in existence, two refused to participate, two would respond only to a written questionnaire, and seven could not be contacted. After being assured of the anonymity of information, 40 (80%) of the plans responded to questions soliciting information about preventive health services that were currently available. (See listing of Survey questions.) The four bar graphs appended to this section (Figs. l-4) show the percentage of the 40 respondents providing particular health services. Data are separately presented for 15 plans of over 10,000 enrollees each, and 25 plans of under 10,000 members each as of December 31, 1972. As an example of how the information obtained can be read for these graphs, let us consider the question dealing with voluntary family planning. Of the 40 plans surveyed, 38 (95%) responded to this question. Of these, 92% said that

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they either currently offered or paid for family doing so only on the referral of a plan physician. 10,000 enrollees, 83% offered this benefit, with physician referral. Within the plans of less than was offered 96% of the time with 19% requiring physician approval. It is apparent that of the services tested, those those least often found. SURVEY

planning services, with 16% Among the plans with over only 8% of these requiring 10,000 members, this benefit the members to first obtain dealing with dental care are

QUESTIONS

1. Is the plan equipped to offer (or pay for) voluntary family planning? 2. Is the plan equipped to offer (or pay for) infertility services? 3. Do you provide preventive dental services? 4. Are children routinely given vision exams? 5. Do you offer any programs in “health education?” 6.(a) Are infants routinely given a full series of immunizations? (b) Are adult immunizations routinely given? (c) Are children routinely given a full series of immunizations? 7. Do you offer (or pay for) psychiatric/psychological treatment? 8. Do you treat (or pay for) alcohol-related illnesses? 9. Do you treat (or pay for) drug-related illnesses? 10. Do you provide dental treatment? 11. Is an initial health assessment a prerequisite for enrollment in your plan? 12. Do you routinely make a “health hazards” appraisal on your enrollees? 13. Are your subscribers entitled to an annual or periodic health exam? 14. Do the patients routinely fill out a self-administered health history before their first/and for all subsequent exams? 15. Do you offer (or pay for) genetic counseling? 16. Do you offer a full range of standard prenatal services? 17. Do you provide well baby care? 18. Are children routinely given speech exams? 19. Are children routinely given hearing exams? 20. Do you offer mental health services? 2 1. Do you do (or pay for) psychological testing? 22. Do you treat (or pay for) and offer therapy to individuals who have engaged in self-destructive behavior? V. ECONOMIC FACTORS INVOLVED IN SELECTING THE NATURE AND EXTENT OF PREVENTIVE HEALTH CARE SERVICES TO BE PROVIDED BY AN HMO Introduction

There are a number of factors which have to be taken into account when selecting preventive health strategies for inclusion in the HMO coverage. Among these are: which of these strategies have proved beneficial in reducing

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Voluntary Family Planning

Infertility Servicer

CARE STRATEGIES Preventive Dental Services

FOR HMOS

217

Health Education

EYE Examinations

loor w8070 e j

60M-

88

74

4030-20 10 OTotal Number =-lO.WO Members CIO,WJll Members

38

:I’

20

13

7 LLJ

: 3.;

7

25

i.

10.

38 12

15 26

23

0 General Coverage EXJ Covered only upon request

24

or recommendation

25 of plan physician

FIG. 1. Six major preventive health services currently required shows availability of these services.

Psychiatric/ Psychological Treatment

Total Number > lO.wO Members c lO.OC0 Members El IZJ

Treatment of Alcoholism

37

Treatment of Addiction

39 15

22

be provided by HMOs. Graph

Dental Treatment

Drug

38 15

to

39 15

23

General coverage Covered only upon request or recommendation

15 24

24

of plan physician

2. Figure shows the availability of four supplementary preventive health services. It is recommended that HMOs be required to provide these services in addition to those in Fig. 1.

FIG.

218

PEACOCK, Initial Screening

GELMAN

AND LUTINS

Periodic Health Examination

Health Hazard Appraisal

Health History

Genetic Counseling Service

Prenatal Service

mlUJEO70 JO

Total Number a 10,ooO Members < lO.oW Members c7 m

38

35

40 15

15 23 20 25 General coverage Covered only upon request or recommendation of plan physician 15

Well Baby Care

Examination

Hearing Examinatik

38

40

Mental Health Services.

loo,

25

26

Psychiatric/ Psychological Testing

Suicide Treatment & Prevention

90&l-

70 -im 8 t 5040M2010 oTotal Number =-lO.oM) Members

Preventive health care strategies for health maintenance organizations.

PREVENTIVE 4, 183-225 MEDICINE (1975) SPECIAL REPORT Preventive Health Care Strategies for Health Maintenance Organizations PETER B. PEACOCK Ameri...
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