Annals of Internal Medicine is published by the American College of Physicians-American Society of Internal Medicine (ACP-ASIM), an organization of more than 115,000 internal medicine physicians and medical students. The following highlights are not intended to substitute for articles as sources of information. For an embargoed fax of an article, call 1-800-523-1546, ext. 2656 or 215-351-2656.
Many U.S. Adults Are Not Protected Against Diphtheria and Tetanus
Annual Physical: Needless Ritual or Necessary Routine?
Physicians Can Increase Use of Adult Immunization and Cancer Screening Services by Reorganizing Their Prevention Practices
Overall, only 60.5 percent of Americans were fully protected against diphtheria and 72.3 percent against tetanus in the period from 1988 to 1994, an analysis of data from a large national study found (Article, p. 660). Older people were much less likely to have immunity than younger people. Among 70 year olds, only 29.5 percent were immune to diphtheria and 31.0 percent to tetanus. Mexican-American adults were less likely to have immunity than other ethnic groups. People living at the poverty level were less likely to be immune to diphtheria than the wealthy.
Both diseases are rare in the United States, where infants and children are routinely immunized. However, both are more common in some parts of the world, and tetanus is highly fatal. If immunity is not maintained in the overall population, infections can re-emerge, as they have in the Soviet Union.
The study authors say that adults should have booster doses of tetanus and diphtheria toxoid every 10 yearThey call uponphysicians make these immunizations a routine part of patient care.
Two-thirds of people in a three-city telephone survey thought they needed an annual physical exam, although current medical guidelines do not recommend one for healthy adults (Article, p. 652). People were more interested in many non-recommended laboratory tests, such as complete blood counts and tests of kidney function, than in recommended tests, such as Pap tests, mammography and colon cancer screening tests. Unnecessary office visits and tests add considerably to the overall cost of health care.
Half the people in the survey were also given information on the cost of the annual physical and some tests. The more people had to pay for the annual physical and specific tests, the less they wanted them.
The authors say that the public should know current recommendations for specific preventive health services and why some aspects of yearly checkups have little value.
But an accompanying editorial points out many of the reasons why an annual physical is still important, despite recommendations to the contrary (Editorial, p. 701). Physicians find it difficult to fit prevention and screening tests into office visits for other health reasons in today's health care environment. The track record for preventive services in U.S. health care is far from perfect. (See article on rates of adult immunization and cancer screening services in this issue of Annals, p. 641, described below.)
Much as well-baby visits set aside time for concentrating on pediatric prevention issues, the editorial writer says, "annual examinations provide the opportunity to plug cracks in the system and assure that patients are getting indicated preventive care." More research is needed on the impact of an annual examination on a patient's health perceptions and behavior. "If careful study documents that patients who get annual examinations feel better, behave healthier, undergo more appropriate screening, and trust their physicians more than patients who do not have annual examinations, skeptics would need to reconsider the value of this yearly ritual," the writer says.
Certain tests and procedures, such as immunizations and cancer screening, prevent illness and find disease, which then can be treated in its early stages. Yet many adults who have a regular physician don't get these proven procedures. A study finds that the best way to increase immunizations and cancer screening is for health systems and physician practices to reorganize the delivery of preventive services (Article, p. 641). The most effective changes were to set up separate clinics for prevention; schedule specific clinic visits just for prevention, and use staff other than doctors to provide preventive services. Financial incentives for patients, such as reducing or eliminating copayments, also helped increase use of immunization and cancer screenings. Teaching patients and clinicians was the least effective technique studied.