The Relative Merits of Population-Based and Targeted Prevention Strategies
Article first published online: 21 NOV 2008
© 2008 Milbank Memorial Fund
Volume 86, Issue 4, pages 557–580, December 2008
How to Cite
ZULMAN, D. M., VIJAN, S., OMENN, G. S. and HAYWARD, R. A. (2008), The Relative Merits of Population-Based and Targeted Prevention Strategies. Milbank Quarterly, 86: 557–580. doi: 10.1111/j.1468-0009.2008.00534.x
- Issue published online: 21 NOV 2008
- Article first published online: 21 NOV 2008
- Risk stratification;
- multivariable prediction tools;
Context: Preventive medicine has historically favored reducing a risk factor by a small amount in the entire population rather than by a large amount in high-risk individuals. The use of multivariable risk prediction tools, however, may affect the relative merits of this strategy.
Methods: This study uses risk factor data from the National Health and Nutrition Examination Survey III to simulate a population of more than 100 million Americans aged thirty or older with no history of CV disease. Three strategies that could affect CV events, CV mortality, and quality-adjusted life years were examined: (1) a population-based strategy that treats all individuals with a low- or moderate-intensity intervention (in which the low-intensity intervention represents a public health campaign with no demonstrable adverse effects), (2) a targeted strategy that treats individuals in the top 25 percent based on a single risk factor (LDL), and (3) a risk-targeted strategy that treats individuals in the top 25 percent based on overall CV risk (as predicted by a multivariable prediction tool). The efficiency of each strategy was compared while varying the intervention's intensity and associated adverse effects, and the accuracy of the risk prediction tool.
Findings: The LDL-targeted strategy and the low-intensity population-based strategy were comparable for CV events prevented over five years (0.79 million and 0.75 million, respectively), as were the risk-targeted strategy and moderate-intensity population-based strategy (1.56 million and 1.87 million, respectively). The risk-targeted strategy, however, was more efficient than the moderate-intensity population-based strategy (number needed to treat [NNT] 19 vs. 62). Incorporating a small degree of treatment-related adverse effects greatly magnified the relative advantages of the risk-targeted approach over other strategies. Reducing the accuracy of the prediction tool only modestly decreased this greater efficiency.
Conclusions: A population-based prevention strategy can be an excellent option if an intervention has almost no adverse effects. But if the intervention has even a small degree of disutility, a targeted approach using multivariable risk prediction can prevent more morbidity and mortality while treating many fewer people.