Shift Left: Prioritizing Prevention in Healthcare

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The global shift in morbidity and mortality from communicable to noncommunicable disease is well documented.1 In the United States, there is also a rise in the number of patients – both adult and pediatric – who suffer from more than one disease.2 Moreover, as we have seen in the COVID-19 pandemic, chronic diseases, like obesity, increase the severity and contractibility of communicable diseases.3 ((Kwok S, Adam S, Ho JH, et al. Obesity: A critical risk factor in the COVID-19 pandemic. Clin Obes. 2020;10(6):e12403.)) This phenomenon is a reminder that, while constructs are helpful in studying diseases, the human body is still one interconnected system and employing siloed approaches will not always prove efficacious.4

Important distinctions have been made between the medical provider’s clinical responsibility for her individual patients’ health and the public health practitioner’s responsibility for community wellness. Specifically, while the medical provider may focus on reducing hypertension for an individual, or to the left on a Cartesian graph, the population-level health practitioner is focused on implementing an aggregate reduction that could happen without necessarily addressing the individual in the aforementioned situation.5 The public health practitioner wants to shift the curve to the left so that overall blood pressure for the population moves closer to normal. Ultimately, the clinical provider and the public health practitioner both care about community health outcomes and the individual; the scope of their work is simply different.6

It is well-documented that treating chronic disease requires a multi-pronged intervention that can be both costly and require a significant time commitment.7 ((Bray GA, Frühbeck G, Ryan DH, Wilding JPH. Management of obesity. The Lancet. 2016;387(10031):1947-1956.)) Moreover, it is well-documented that providers do not have sufficient time, and often lack the appropriate training, to facilitate the necessary interventions.8 As a result, our healthcare system has become highly reliant on tertiary prevention, which includes costly medications and surgeries.9

There are opportunities to “shift left”: in terms of incentivizing and prioritizing primary and secondary prevention, and in terms of addressing a more upstream etiology, like stress.10 Prevention is a proven, timeless strategy to reduce the burden of disease and improve health outcomes.11 ((Gordis L. Epidemiology. Philadelphia, pA: Elsevier/Saunders; 2014.)) Regardless of the metric – be it morbidity, mortality, or cost – shifting left in addressing a more upstream cause of disease and in our prevention leads to better individual and communal health outcomes.5  

Josh Yudkin
  1. Alwan A, World Health O. Global status report on noncommunicable diseases 2010. Geneva, Switzerland: World Health Organization; 2011. []
  2. (CDC) CfDC. Chronic Diseases in America. In: (CDC) CfDC, ed. CDC’s National Center for Chronic Disease Prevention and Health Promotion. United States of America: Centers for Disease Control (CDC); 2021. []
  3. Gao F, Zheng KI, Wang X-B, et al. Obesity Is a Risk Factor for Greater COVID-19 Severity. Diabetes Care. 2020;43(7):e72-e74. []
  4. Snyderman R, Weil AT. Integrative Medicine: Bringing Medicine Back to Its Roots. Archives of Internal Medicine. 2002;162(4):395-397. []
  5. Keyes KM, Galea S. Population health science. Oxford ; New York, NY: Oxford University Press; 2016. [] []
  6. El-Sayed AM, Galea S. Systems science and population health. Oxford ; New York: Oxford University Press; 2017. []
  7. Janicke DM, Steele RG, Gayes LA, et al. Systematic review and meta-analysis of comprehensive behavioral family lifestyle interventions addressing pediatric obesity. J Pediatr Psychol. 2014;39(8):809-825. []
  8. Ben-Sefer E. The childhood obesity pandemic: Promoting knowledge for undergraduate nursing students. Nurse Educ Pract. 2009;9(3):159-165. []
  9. Council NR. US health in international perspective: shorter lives, poorer health. In: Panel on Understanding Cross-National Health Differences Among High-Income Countries. Committee on Population, Division of Behavioral and Social Sciences and Education, and Board on Population Health and Public Health Practice. National Academies Press Washington, DC; 2013. []
  10. Johnson KB RSD. Understanding Microinflammation: The Common Link Between Aging, Cancer and Coronary Disease. United States of America: Createspace Independent Pub; 2014. []
  11. Rothman KJ, Greenland S, Lash TL. Modern epidemiology. 3rd ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2008. []

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