摘要：Healthy aging must become a priority objective for both population and personal health services, and will require innovative prevention programming to span those systems. Uptake of essential clinical preventive services is currently suboptimal among adults, owing to a number of system- and office-based care barriers. To achieve maximum health results, prevention must be integrated across community and clinical settings. Many preventive services are portable, deliverable in either clinical or community settings. Capitalizing on that flexibility can improve uptake and health outcomes. Significant reductions in health disparities, mortality, and morbidity, along with decreases in health spending, are achievable through improved collaboration and synergy between population health and personal health systems. BETWEEN 2010 AND 2050 , the population of Americans aged 65 years and older is expected to more than double, swelling to nearly 89 million. This “silver tsunami,” composed mostly of Baby Boomers (the first of whom crossed the 65-year line in 2011), will pose serious challenges for our nation’s public health and health care systems, along with state and federal budgets, family finances, and private sector profitability. Healthy aging, too often viewed as a peculiar product of luck or luxury, must become a priority objective for both population and personal health services—and will require innovative prevention programming to span those systems. Chronic illness currently represents an estimated 83% of total US health expenditures and 99% of Medicare spending. 1 Increasing rates of costly chronic conditions, many of which are not well managed, 2–5 are associated with significant Medicare spending increases. 6,7 Each year, more than half of Medicare beneficiaries are treated for 5 or more chronic conditions. 6 The average Medicare enrollee sees 2 primary care physicians and 5 specialists working in 4 different practices annually 8 ; those with 5 or more chronic conditions see an average of 14 different physicians a year. 9 Care fragmentation results in suboptimal uptake of clinical preventive services (CPS) among US adults 3,10 : only 33% of women and 40% of men aged 65 years and older are fully up to date with all preventive services recommended for all adults in this age range, 11 and less than a quarter of adults aged 50 to 64 years have received all these services. 12 Even if adults receive recommended disease screening, a positive finding may not lead to effective treatment: although blood pressure screening in older adults is relatively high, hypertension is controlled in only half of patients. 13 Preventing chronic diseases and keeping chronically ill older adults healthier are imperatives to drive improvements in health, quality of life, and value in US health spending. 14 Population-based primary prevention works to avert disease. It must be reinforced with patient-focused primary prevention and coupled with effective secondary prevention to detect illness as well as tertiary prevention aimed at better managing existing illness and preventing additional disease and disability. To achieve maximum health results, prevention must be integrated across community and clinical settings. Many preventive services are portable—deliverable in either clinical or community settings. Capitalizing on that flexibility can improve uptake and health outcomes. Optimal use of CPS—particularly for cardiovascular conditions—could avert an estimated 50 000 to 100 000 deaths per year among adults younger than 80 years and 25 000 to 40 000 deaths per year among those younger than 65 years. 15 Increasing uptake of selected high-value CPS to 90% could produce an additional 1.89 million quality-adjusted life years. 16 Outside clinical settings, the Trust for America’s Health has estimated that an investment of $10 per person per year in community-based programs tackling physical inactivity, poor nutrition, and smoking could yield more than $16 billion in medical cost savings annually within 5 years—a return on investment of $5.60 for every $1 spent, without considering the additional gains in worker productivity, reduced absenteeism at work and school, and enhanced quality of life. 17 Significant reductions in health disparities, mortality, and morbidity—and attendant decreases in health spending—are achievable through improved collaboration and synergy between population health and personal health systems. 18 We discuss essential CPS for older adults, emerging delivery models that encompass health care and community settings to boost uptake, and public health priorities in a changing US health system.
