From Prevention Science to Services: Identifying Paths to Sustainable Evidence-Based Preventive Interventions

Although an ounce of prevention is worth a pound of cure, the U.S. health care system often favors treatment of mental disorders over their prevention. Preventing mental disorders (including substance use disorders) is essential to improving public health. Avoiding onset or progression of mental disorders minimizes associated harms and allows individuals to reach their fullest potential. Only a minority of individuals with mental disorders ever seek treatment, and when treatment is received, it is often not evidence based (1). Increasing the role of prevention could complement the role of treatment and help achieve the quintuple aim of health care by improving population health, enhancing the care experience, helping contain costs, preventing clinician burnout, and achieving equity (2).

Prevention programs, such as screening and referral to interventions, designed to prevent mental disorders and substance use initiation include selective interventions for individuals at increased risk for a health outcome and indicated interventions for those who are already showing symptoms or behaviors; these programs have the potential for cost savings by, for example, substantially reducing health care costs associated with risky behaviors (3). Despite the potential for cost savings, the demonstration of efficacy of an intervention in research studies does not automatically translate into the intervention being sustained, because funding may not be available to pay for it.

In the United States, prevention services are supported by various payers, each with different mandates and criteria for the allocation of funds. Although securing consistent funding for prevention services long term will likely require multilevel solutions (e.g., policy changes and new funding structures), a key complementary strategy is to align research studies with the evidentiary requirements of existing funding sources in order to increase the likelihood of funding for a program after a research study ends. An improved understanding of the research evidence considered by payers could help investigators develop prevention intervention studies, including those funded by NIH, that better meet evidentiary requirements, facilitating the translation of prevention research into funded, scalable, and sustainable prevention services. This Viewpoint provides examples of how investigators could better align research questions, methodology, and outcomes to payer requirements.

Pathways to Prevention

One pathway for coverage of preventive interventions is through the Patient Protection and Affordable Care Act (ACA). The ACA mandates that preventive services endorsed with a grade A or B by the U.S. Preventive Services Task Force (USPSTF) must be covered by insurance plans and policies without cost sharing by patients. The USPSTF is an independent volunteer panel of prevention experts that commissions evidence reviews of preventive services (see https://www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and-processes/procedure-manual/procedure-manual-section-3-topic-work-plan-development), conducted by Agency for Healthcare Research and Quality–designated Evidence-Based Practice Centers. On the basis of the evidence reviewed and identified, the USPSTF assigns interventions a grade to guide the practice of primary care clinicians—A or B grades are for recommended interventions, which are covered by insurance; interventions with C grades are recommended for select populations, and interventions with D grades are discouraged.

An I grade indicates insufficient evidence to assess the balance of benefits and harms of an intervention. For example, primary care–based interventions for illicit drug use among children, adolescents, and young adults are currently graded I. The USPSTF has provided a list of areas with evidence gaps, including the need for research on prevention of cannabis use, research that addresses both benefits and harms of an intervention, replication studies of existing interventions, and research on technology-based interventions (e.g., text messaging). Research that addresses these evidentiary gaps can help move the USPSTF recommendation from a grade I to A, B, or C, thereby enabling translation from experimental study to clinical intervention, guaranteeing coverage for these interventions, and facilitating their scalability and sustainability. Such research can also lead to the important conclusion that an intervention is harmful.

A second system to consider is child welfare. Under the 2018 Family First Prevention Services Act (FFPSA), states have the option of using Title IV-E funding to provide evidence-based substance use and mental health treatment and prevention services to youths and families for 1 year to prevent youths’ entry into foster care. Title IV-E funds can be used for services or programs rated as “promising,” “supported,” or “well supported” by the Title IV-E Prevention Services Clearinghouse, increasing the likelihood that states will adopt and implement the intervention (4).

Research studies that fulfill the requirements of Title IV-E would help ensure that the interventions could be supported as ongoing services, beyond the research phase. To fulfill some of the evidentiary requirements for a well-supported rating, FFPSA legislation requires at least two studies of an intervention that are determined to be well designed and well executed by an independent review or by randomized controlled trials or rigorous quasi-experimental designs and carried out in usual care or practice settings. At least one of the studies must show a postintervention effect for 1 year or longer (4).

A third avenue for supporting prevention services is funding from states, counties, or local jurisdictions through Substance Abuse Prevention and Treatment Block Grants (SABGs) of the Substance Abuse and Mental Health Services Administration (SAMHSA) or through state or local taxes. State-based funds sometimes require that a percentage be allocated to prevention strategies (e.g., at least 20% in the case of SAMHSA SABGs). However, funding eligibility for preventive interventions varies considerably among states. This variation interferes with the ability of researchers to chart a path from intervention development to implementation, scalability, and sustainability. Use of standardized criteria for intervention selection, such as reliance on national registries to determine which programs are evidence based (as some states already do), would help researchers design studies to fulfill those criteria and accelerate translation from intervention development to public health benefit. Each state has at least one prevention resource point of contact, the National Prevention Network (NPN) representative. In designing studies, researchers may consider opportunities to partner with NPNs, single state agencies, or other relevant local authorities that administer funds to better understand the criteria used in each jurisdiction to determine the allocation of prevention funds to specific programs.

Increased Collaboration

For funders of prevention services, increased collaboration with researchers could help ensure that evidentiary requirements are met, helping to accelerate the translation from experimental science to funded services. Ongoing collaboration could generate feedback loops in which the funding agencies and the public identify needed refinements in the interventions that could then be addressed by researchers, extending the approaches of existing learning health care systems to prevention services (5).

For researchers, collaboration with funders of preventive services could facilitate studies that address prevention needs identified by communities and that consider intervention costs from the outset. Collaboration with funders could also help spur innovation and stimulate the development of preventive interventions to be delivered in less traditional settings in order to respond to community needs. The search for collaborators may help identify agencies that do not currently provide funding for preventive services but might benefit from funding such services if doing so helps offset other costs, such as those associated with homelessness or increased crime levels.

When writing notices of funding opportunities, research funders can direct applicants to the evidentiary requirements of potential payers. Two National Institute on Drug Abuse announcements that were focused on prevention in the child welfare system (RFA-DA-24–011 and RFA-DA-24–012) encouraged applicants to consider the criteria specified in the Title IV-E Prevention Services Clearinghouse Handbook of Standards and Procedures when designing their study.

As preventive interventions are developed, ensuring that research is designed from the outset to inform the evidentiary requirements of potential payers is essential. Developing interventions that are scalable and sustainable remains a key principle to prioritize research; stimulate discussions among researchers, public health officials, and health systems administrators; and, ultimately, help translate knowledge into health.