Heidi D. Nelson, MD, MPH; Amy Cantor, MD, MPH; Jesse Wagner, MA; Rebecca Jungbauer, DrPH, MPH, MA; Ana Quiñones, PhD, MS; Lucy Stillman, BS; Karli Kondo, PhD, MA
Disclaimer: The findings and conclusions in this article are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ or NIH. Therefore, no statement in this report should be construed as an official position of NIH, AHRQ, or the U.S. Department of Health and Human Services.
Acknowledgment: The investigators acknowledge the contributions of Lionel L. Bañez, MD, AHRQ Task Order Officer; NIH partners; technical expert panel members; peer reviewers; Somnath Saha, MD, MPH, content expert; Tracy Dana, MLS, librarian; Bernadette Zakher, MBBS, MPH, research associate; and Melanie Timmins and Rachel Lockard, MPH, student research assistants.
Financial Support: This report is based on research conducted under contract to the AHRQ, Rockville, Maryland (contract 290-2015-00009I), and funded by the NIH Office of Disease Prevention.
Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M19-3199.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Christina C. Wee, MD, MPH, Deputy Editor, reports employment with Beth Israel Deaconess Medical Center. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Yu-Xiao Yang, MD, MSCE, Deputy Editor, reports that he has no financial relationships or interest to disclose.
Reproducible Research Statement:Study protocol: Registered in PROSPERO (CRD42018109263). Statistical code: Not applicable. Data set: See the Supplement. Additional information is available from the investigators.
Corresponding Author: Heidi D. Nelson, MD, MPH, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mailcode BICC, Portland, OR 97239; e-mail, email@example.com.
Current Author Addresses: Drs. Nelson, Cantor, Jungbauer, Quiñones, and Kondo; Mr. Wagner; and Ms. Stillman: Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mailcode BICC, Portland, OR 97239.
Author Contributions: Conception and design: H.D. Nelson, A. Cantor, L. Stillman, K. Kondo.
Analysis and interpretation of the data: H.D. Nelson, A. Cantor, J. Wagner, R. Jungbauer, A. Quiñones, K. Kondo.
Drafting of the article: H.D. Nelson, A. Cantor, J. Wagner, R. Jungbauer, A. Quiñones, L. Stillman, K. Kondo.
Critical revision of the article for important intellectual content: H.D. Nelson, A. Cantor, J. Wagner, R. Jungbauer, A. Quiñones, K. Kondo.
Final approval of the article: H.D. Nelson, A. Cantor, J. Wagner, R. Jungbauer, A. Quiñones, L. Stillman, K. Kondo.
Provision of study materials or patients: H.D. Nelson, J. Wagner.
Obtaining of funding: H.D. Nelson, A. Cantor.
Administrative, technical, or logistic support: H.D. Nelson, A. Cantor, J. Wagner, R. Jungbauer, L. Stillman.
Collection and assembly of data: H.D. Nelson, A. Cantor, J. Wagner, R. Jungbauer, A. Quiñones, L. Stillman.
Disadvantaged populations in the United States experience disparities in the use of preventive health services.
To examine effects of barriers that create health disparities in 10 recommended preventive services for adults, and to evaluate the effectiveness of interventions to reduce them.
English-language searches of Ovid MEDLINE, PsycINFO, SocINDEX, and the Veterans Affairs Health Services database (1 January 1996 to 5 July 2019); reference lists.
Trials, observational studies with comparison groups, and systematic reviews of populations adversely affected by disparities that reported effects of barriers on use of any of the 10 selected preventive services or that reported the effectiveness of interventions to reduce disparities in use of a preventive service by improving intermediate or clinical outcomes.
Dual extraction and assessment of study quality, strength of evidence, and evidence applicability.
No studies reported effects of provider-specific barriers on preventive service use. Eighteen studies reporting effects of patient barriers, such as insurance coverage or lack of a regular provider, on preventive service use had mixed and inconclusive findings. Studies of patient–provider interventions (n = 12), health information technologies (n = 11), and health system interventions (n = 88) indicated higher cancer screening rates with patient navigation; telephone calls, prompts, and other outreach methods; reminders involving lay health workers; patient education; risk assessment, counseling, and decision aids; screening checklists; community engagement; and provider training. Single studies showed that clinician-delivered and technology-assisted interventions improved rates of smoking cessation and weight loss, respectively.
Insufficient or low strength of evidence and applicability for most interventions except patient navigation, telephone calls and prompts, and reminders involving lay health workers.
In populations adversely affected by disparities, patient navigation, telephone calls and prompts, and reminders involving lay health workers increase cancer screening.
National Institutes of Health Office of Disease Prevention through an interagency agreement with the Agency for Healthcare Research and Quality. (PROSPERO: CRD42018109263)
The diagram illustrates the multiple levels of influence that affect successful navigation of the preventive service clinical pathway.
Table 1. Preventive Services Included in the Review
Evidence search and selection.
The diagram indicates the number of abstracts and full-text articles reviewed for inclusion and subsequently included or excluded. KQ = key question; VA HSR&D = Veterans Affairs Health Services Research and Development Service.
* Additional sources include suggested references and reference lists.
† Some studies are included in multiple KQs.
Table 2. Summary of Evidence
Nelson HD, Cantor A, Wagner J, et al. Achieving Health Equity in Preventive Services: A Systematic Review for a National Institutes of Health Pathways to Prevention Workshop. Ann Intern Med. 2020;:. [Epub ahead of print 14 January 2020]. doi: https://doi.org/10.7326/M19-3199
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Published: Ann Intern Med. 2020.
Cardiology, Coronary Risk Factors, Healthcare Delivery and Policy, Prevention/Screening, Smoking.
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