Integrating Evidence-Based Clinical and Community Strategies to Improve Health

Abstract

Multiple and diverse preventive strategies in clinical and community settings are necessary to improve health. This paper (1) introduces evidence-based recommendations from the U.S. Preventive Services Task Force sponsored by the Agency for Healthcare Research and Quality and the Community Task Force sponsored by the Centers for Disease Control and Prevention, (2) examines, using a social-ecologic model, the evidence-based strategies for use in clinical and community settings to address preventable health-related problems such as tobacco use and obesity, and (3) advocates for prioritization and integration of clinical and community preventive strategies in the planning of programs and policy development, calling for additional research to develop the strategies and systems needed to integrate them.

Introduction

Unhealthy lifestyle behaviors and risk factors, poor delivery of clinical and community preventive services, and environments not conducive to health increase the risk of disease and injury and contribute to the leading causes of death (Table 1).1, 2 (We use the term “clinical” to include primary care in healthcare systems as well as solo practices, and the term “community” to include a range of geopolitical units from small-community interconnected groups to entire countries, continents, and the globe.) Tobacco use, poor diet, and physical inactivity alone contribute to more than a third of the premature deaths in the United States.1, 2

Disease and injury are not inevitable. A growing body of evidence-based preventive strategies is available to reduce the preventable burden of disease, that is, the amount of disease that could be averted if preventive and therapeutic services were universally delivered.³ Parts of the burden can be prevented through the delivery of appropriate clinical preventive services, through community-level interventions, and through appropriate treatment (see lower bar on Figure 1). The remainder is unavoidable at present due to the limits of current knowledge and will require additional research.

Clinical, medical, and community interventions have contributed to reducing the burden of illness; the impact of these interventions is illustrated in Figure 1 (see top bar) as what has been prevented. The gap between what is avoidable through these interventions, and what we currently achieve represents the translation gap, that is, the failure to translate effective clinical and community-level services into practice. This information can be used to guide efforts to improve preventive care. The relative balance and prioritization of interventions should be based on a clear understanding of what can be achieved--the preventable burden attributable to each, and their relative value--cost effectiveness along with important qualitative factors to ensure successful implementation. Although Figure 1 portrays the clinical and community interventions as discrete, as we discuss below, they should be viewed as synergistic and integratable.4, 5

Two established national expert panels, the U.S. Preventive Services Task Force (USPSTF) and the Community Task Force (CTF) (henceforth Task Forces), specifically recommend evidence-based preventive strategies in clinical and community settings, respectively, in order to reduce the preventable burden of disease. Their recommendations are made on the basis of rigorous review of research-generated evidence and provide essential information for selecting and prioritizing effective preventive strategies. Members of both Task Forces are nonfederal experts drawn from academia, state and local governments, and the private sector, and both Task Forces work closely with a range of federal and nonfederal experts in science, program, and policy. The USPSTF and CTF are convened and supported by the Agency for Healthcare Research and Quality and the Centers for Disease Control and Prevention, respectively.

This paper provides an overview of the work of the two Task Forces, discusses the complementary nature of their recommendations (Table 2), and notes the importance of prioritizing and integrating clinical and community efforts for achieving optimal disease prevention and control. A social-ecologic framework⁷ (Figure 2) is used to include both perspectives and to organize examples of clinical and community evidence-based interventions. An example (tobacco) is provided where both clinical and community strategies have strong evidentiary support. Another example (obesity) is provided in which the primary challenge is integration where there are identified gaps in studies and syntheses. This example illustrates opportunities for improvement and research. Finally, some of the resources needed to address challenges to integration are considered.